Provider Demographics
NPI:1598392011
Name:VARGHESE, BLAKE
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:VARGHESE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5403 NORMANDY ST
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:WI
Mailing Address - Zip Code:54476-2217
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:715-241-8102
Practice Address - Street 1:5403 NORMANDY ST
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WI
Practice Address - Zip Code:54476-2217
Practice Address - Country:US
Practice Address - Phone:715-241-8100
Practice Address - Fax:715-241-8102
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1300-25213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery