Provider Demographics
NPI:1104112572
Name:BLAKE, BENJAMIN JAY (DO)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:JAY
Last Name:BLAKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:536 CARRIAGE ESTATES RD
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75092-4444
Mailing Address - Country:US
Mailing Address - Phone:940-594-8560
Mailing Address - Fax:
Practice Address - Street 1:5016 S US HIGHWAY 75
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020-4584
Practice Address - Country:US
Practice Address - Phone:903-416-2435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP5037207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine