Provider Demographics
NPI:1316978174
Name:SMITH, BLAKE ALLEN (DPM)
Entity type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:ALLEN
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPM
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 917
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60065-0917
Mailing Address - Country:US
Mailing Address - Phone:847-504-5000
Mailing Address - Fax:847-504-5015
Practice Address - Street 1:40 SKOKIE BLVD STE 520
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-1601
Practice Address - Country:US
Practice Address - Phone:847-504-5000
Practice Address - Fax:847-504-5015
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004391213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN07000838OtherIN LICENSE
IL016004391OtherIL LICENSE
IN200136480EMedicaid
IN859800FOtherADMINISTAR FEDERAL PIN
INP01675626OtherRAILROAD MEDICARE
IL016004391Medicaid
IL480017243OtherRAILROAD MEDICARE
ILL74904Medicare PIN
IL016004391OtherIL LICENSE
U11854Medicare UPIN
INP01675626OtherRAILROAD MEDICARE