Basic Information
| Provider Information | |||||||||
| NPI: | 1336469444 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ISERNHAGEN | ||||||||
| FirstName: | BLAKE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 N EAGLE CREEK DR | ||||||||
| Address2: | STE 500 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405091827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592633900 | ||||||||
| FaxNumber: | 8592633757 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 N EAGLE CREEK DR | ||||||||
| Address2: | STE 500 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592633900 | ||||||||
| FaxNumber: | 8592633757 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2010 | ||||||||
| LastUpdateDate: | 08/22/2018 | ||||||||
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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 | 207W00000X | 48761 | KY | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207WX0107X | 48761 | KY | Y |
ID Information
| ID | Type | State | Issuer | Description | 1336469444 | 05 | WV | MEDICAID | 0163986 | 05 | OH | MEDICAID | 200312510A | 05 | OK | MEDICAID | 300015774 | 05 | IN | MEDICAID | 7100400550 | 05 | KY | MEDICAID |