Healthcare Provider Details

I. General information

NPI: 1053057463
Provider Name (Legal Business Name): BLAKE JEFFREY MCKINLEY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2022
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 CIRCLE OF HOPE DR RM LL376
SALT LAKE CITY UT
84112-5550
US

IV. Provider business mailing address

2000 CIRCLE OF HOPE DR RM LL376
SALT LAKE CITY UT
84112-5550
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2121
  • Fax:
Mailing address:
  • Phone: 801-581-2121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number14214224-1204
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS20751
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: