Provider Demographics
NPI:1699272567
Name:LE GRAND, BLAKE ALLISTER (MD)
Entity type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:ALLISTER
Last Name:LE GRAND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 1/2 WOLDEN RD APT C2-8
Mailing Address - Street 2:
Mailing Address - City:OSSINING
Mailing Address - State:NY
Mailing Address - Zip Code:10562-5312
Mailing Address - Country:US
Mailing Address - Phone:347-992-0736
Mailing Address - Fax:
Practice Address - Street 1:325 S HIGHLAND AVE STE 106
Practice Address - Street 2:
Practice Address - City:BRIARCLIFF MANOR
Practice Address - State:NY
Practice Address - Zip Code:10510-2054
Practice Address - Country:US
Practice Address - Phone:914-366-0015
Practice Address - Fax:914-366-0012
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA11081300208000000X
NY308910208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics