MEDICARE: BLAKE CLUTTER

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	390200000X	Student in an Organized Health Care Education/Training Program
2	207Q00000X	Family Medicine Physician	02007088A	IN

General Provider Information

NPI Number	:	1699356303
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BLAKE CLUTTER

Provider Business Mailing Address
First Line	:	8535 N CLEARVIEW DR
Second Line	:
City	:	MCCORDSVILLE
State	:	IN
Zip	:	46055-6240
Country	:	US
Telephone Number	:	317-477-6938
Fax Number	:	317-477-6409

Provider Business Practice Location Address
First Line	:	8535 N CLEARVIEW DR
Second Line	:
City	:	MCCORDSVILLE
State	:	IN
Zip	:	46055-6240
Country	:	US
Telephone Number	:	317-477-6938
Fax Number	:	317-477-6409

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

Provider Enumeration Date	:	04/15/2021
Last Update Date	:	12/06/2024

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Directions to “ BLAKE CLUTTER ” Practice Location

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