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General NPI Number Information
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NPI Number | 1336157015
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Entity Type | Individual
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Provider Name | DEIDRE BLAKE M.D.
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Gender | Female
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Dates
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Enumeration Date | 08/04/2006
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Last Update Date | 09/13/2016
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Provider Practice Location Address
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Address Line | 16 BRENTWOOD DR SUITE A
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City | ITHACA
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State | NY
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Zip | 14850-1863
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Country | US
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Telephone | 607-272-7000
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Fax |
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Provider Business Mailing Address
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Address Line | 16 BRENTWOOD DR SUITE A
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City | ITHACA
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State | NY
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Zip | 14850-1863
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Country | US
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Telephone | 607-272-7000
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207XS0114X
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Taxonomy Name | Adult Reconstructive Orthopaedic Surgery Physician
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License Number | 256896
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License Number State | NY
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