Provider Demographics
NPI:1124698782
Name:MAROTTA, BLAKE (OD)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:MAROTTA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:673 NE 3RD AVE APT 345
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-2742
Mailing Address - Country:US
Mailing Address - Phone:754-317-1129
Mailing Address - Fax:
Practice Address - Street 1:1658 NE MIAMI GARDENS DR
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33179-4900
Practice Address - Country:US
Practice Address - Phone:305-949-4221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5940152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist