MEDICARE: DR. BLAKE JEFFREY FERNANDEZ M.D.

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	207P00000X	Emergency Medicine Physician	ME144848	FL
2	208D00000X	General Practice Physician	ME144848	FL
3	390200000X	Student in an Organized Health Care Education/Training Program
4	207Q00000X	Family Medicine Physician	E-14205	AR

General Provider Information

NPI Number	:	1831624014
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BLAKE JEFFREY FERNANDEZ M.D.

Provider Business Mailing Address
First Line	:	6101 WEBB RD STE 101
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33615-2859
Country	:	US
Telephone Number	:	813-520-0582
Fax Number	:

Provider Business Practice Location Address
First Line	:	6101 WEBB RD STE 101
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33615-2859
Country	:	US
Telephone Number	:	813-520-0582
Fax Number	:

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

Provider Enumeration Date	:	04/26/2017
Last Update Date	:	12/08/2022

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