Provider Demographics
NPI:1336157015
Name:BLAKE, DEIDRE (MD)
Entity type:Individual
Prefix:DR
First Name:DEIDRE
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 BRENTWOOD DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1863
Mailing Address - Country:US
Mailing Address - Phone:607-272-7000
Mailing Address - Fax:
Practice Address - Street 1:16 BRENTWOOD DR
Practice Address - Street 2:SUITE A
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1863
Practice Address - Country:US
Practice Address - Phone:607-272-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY256896207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery