Basic Information
| Provider Information | |||||||||
| NPI: | 1235224718 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAKE | ||||||||
| FirstName: | STEVEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 860554 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32886 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043463606 | ||||||||
| FaxNumber: | 9043460113 | ||||||||
| Practice Location | |||||||||
| Address1: | 3625 UNIVERSITY BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043996811 | ||||||||
| FaxNumber: | 9043460113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 07/19/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME0058519 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 11460 | 01 | FL | BCBS | OTHER |