Provider Demographics
NPI:1093971467
Name:EVANS, BLAKE JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:JOSEPH
Last Name:EVANS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1725 N UNIVERSITY DR STE 400
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33071-6053
Mailing Address - Country:US
Mailing Address - Phone:954-752-3166
Mailing Address - Fax:954-753-5628
Practice Address - Street 1:1725 N UNIVERSITY DR STE 400
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33071-6053
Practice Address - Country:US
Practice Address - Phone:954-752-3166
Practice Address - Fax:954-753-5628
Is Sole Proprietor?:No
Enumeration Date:2008-08-05
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME117404208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL368241OtherAVMED
FLP1011066OtherFREEDOM HEALTH
FL009591500Medicaid
FLP01230859OtherRAILROAD MCR
FL7735843OtherCIGNA
FL1193019OtherWELLCARE
FL14RS8OtherBCBS OF FL
FL4955788OtherAETNA
FLHO039ZMedicare PIN