Provider Demographics
NPI:1154340461
Name:BLAKESLEE, MARK ANDREW (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ANDREW
Last Name:BLAKESLEE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:1 HOSPITAL DR STE 306
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17837-9350
Mailing Address - Country:US
Mailing Address - Phone:570-522-4110
Mailing Address - Fax:570-768-3911
Practice Address - Street 1:3 HOSPITAL DR STE 212
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:PA
Practice Address - Zip Code:17837-9394
Practice Address - Country:US
Practice Address - Phone:570-522-9771
Practice Address - Fax:570-522-9772
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS007656L2084S0012X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00170649OtherRAILROAD MEDICARE
PA645269046OtherGEISINGER
PA50002761OtherKEYSTONE
PA118438711OtherDEPARTMENT OF LABOR
PA170622OtherBLUE SHIELD
PA18423860001Medicaid
PA50002761OtherCAPITAL BLUE CROSS
PA232809429OtherTRICARE
PAG47849OtherHEALTH AMERICA
PA118438711OtherDEPARTMENT OF LABOR
PA232809429OtherTRICARE