Basic Information
| Provider Information | |||||||||
| NPI: | 1811963705 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAKE | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 313 LINWOOD AVE NW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447085624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304552348 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2216 LINCOLN WAY E | ||||||||
| Address2: | |||||||||
| City: | MASSILLON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446467062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308329966 | ||||||||
| FaxNumber: | 3308326007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 08/02/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 5196 | OH | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 51108 | 01 | OH | DAVIS VISION | OTHER | 2601081 | 05 | OH | MEDICAID | 311529091 | 01 | OH | UNITED HEALTH CARE | OTHER | 22683 | 01 | OH | NVA | OTHER | 27426 | 01 | OH | SPECTERA | OTHER | OH5196 | 01 | OH | EYEMED | OTHER | 202699359 | 01 | OH | VSP | OTHER | 202699359 | 01 | OH | TRICARE | OTHER | 311529091 | 01 | OH | PCM | OTHER | OH00213 | 01 | OH | VBA | OTHER |