Healthcare Provider Details

I. General information

NPI: 1255918504
Provider Name (Legal Business Name): BLAKE JORDAN BENNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2021
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 GRESHAM DR
NORFOLK VA
23507-1904
US

IV. Provider business mailing address

134 BUSINESS PARK DR
VIRGINIA BEACH VA
23462-6523
US

V. Phone/Fax

Practice location:
  • Phone: 757-473-0044
  • Fax:
Mailing address:
  • Phone: 757-473-0044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number0101285402
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: