Basic Information
Provider Information | |||||||||
NPI: | 1861412769 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ARNOLD | ||||||||
FirstName: | BLAKE | ||||||||
MiddleName: | W. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 283 E 930 S | ||||||||
Address2: |   | ||||||||
City: | OREM | ||||||||
State: | UT | ||||||||
PostalCode: | 840585001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8012256246 | ||||||||
FaxNumber: | 8012251525 | ||||||||
Practice Location | |||||||||
Address1: | 1380 E MEDICAL CENTER DR | ||||||||
Address2: |   | ||||||||
City: | ST GEORGE | ||||||||
State: | UT | ||||||||
PostalCode: | 847902123 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4356734800 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/20/2006 | ||||||||
LastUpdateDate: | 01/20/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 363889-1205 | UT | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 363889-1205 | UT | N |   | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085B0100X | 363889-1205 | UT | N |   | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085D0003X | 363889-1205 | UT | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Neuroimaging |
ID Information
ID | Type | State | Issuer | Description | 107011790103 | 01 | UT | IHC | OTHER | 870487570BWA | 01 | UT | EMIA | OTHER | 741295 | 01 | UT | DMBA | OTHER | 36388912002001 | 01 | UT | BLUE CROSS | OTHER | 870487570004 | 05 | UT |   | MEDICAID |