Provider Demographics
NPI:1063505105
Name:BLAKE, PERTH AGUSTA (MD)
Entity type:Individual
Prefix:DR
First Name:PERTH
Middle Name:AGUSTA
Last Name:BLAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1245
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-1245
Mailing Address - Country:US
Mailing Address - Phone:352-508-5046
Mailing Address - Fax:
Practice Address - Street 1:1840 CLASSIQUE LN
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-5748
Practice Address - Country:US
Practice Address - Phone:352-508-5046
Practice Address - Fax:352-508-5048
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0069890207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL31711YOtherMEDICARE ID
FL255623500Medicaid
FLG31272Medicare UPIN