MEDICARE: DR. JEFFREY M BLAKE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207VG0400X	Gynecology Physician	01040057A	IN
2	207VF0040X	Urogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician	01040057A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477545127
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY M BLAKE MD

Provider Business Mailing Address
First Line	:	14540 PRAIRIE LAKES BLVD N STE 110
Second Line	:
City	:	NOBLESVILLE
State	:	IN
Zip	:	46060-4370
Country	:	US
Telephone Number	:	317-982-5222
Fax Number	:	317-982-5223

Provider Business Practice Location Address
First Line	:	14540 PRAIRIE LAKES BLVD N STE 110
Second Line	:
City	:	NOBLESVILLE
State	:	IN
Zip	:	46060-4370
Country	:	US
Telephone Number	:	317-982-5222
Fax Number	:	317-982-5223

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/18/2005
Last Update Date	:	11/14/2024

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Directions to “ DR. JEFFREY M BLAKE MD” Practice Location

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