Healthcare Provider Details

I. General information

NPI: 1225074933
Provider Name (Legal Business Name): MARK FRANCIS BLAKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 02/14/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6002 N PORT WASHINGTON RD
MILWAUKEE WI
53217-4902
US

IV. Provider business mailing address

6002 N PORT WASHINGTON RD
MILWAUKEE WI
53217
US

V. Phone/Fax

Practice location:
  • Phone: 414-963-0676
  • Fax: 414-755-0743
Mailing address:
  • Phone: 414-963-0676
  • Fax: 414-755-0743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number51682-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: