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General NPI Number Information
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NPI Number | 1700213972
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Entity Type | Organization
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Legal Business Name | WENDELL O BLAKE MD PA
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Dates
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Enumeration Date | 10/03/2013
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Last Update Date | 10/03/2013
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Provider Practice Location Address
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Address Line | 505 MARTIN LUTHER KING JR AVENUE SUITE 2
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City | LAKELAND
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State | FL
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Zip | 33815-1527
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Country | US
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Telephone | 863-683-5567
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Fax | 863-686-5814
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Provider Business Mailing Address
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Address Line | 505 MARTIN LUTHER KING JR AVENUE SUITE 2
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City | LAKELAND
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State | FL
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Zip | 33815-1527
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Country | US
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Telephone | 863-683-5567
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Fax | 863-686-5814
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Authorized Official
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Title or Position | PRESIDENT
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Name | WENDELL O BLAKE
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Credential | M.D.
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Telephone | 863-683-5567
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | ME0016779
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License Number State | FL
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