Provider Demographics
NPI:1699356303
Name:CLUTTER, BLAKE
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:CLUTTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8535 N CLEARVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MCCORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46055-6240
Mailing Address - Country:US
Mailing Address - Phone:317-477-6938
Mailing Address - Fax:317-477-6409
Practice Address - Street 1:8535 N CLEARVIEW DR
Practice Address - Street 2:
Practice Address - City:MCCORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46055-6240
Practice Address - Country:US
Practice Address - Phone:317-477-6938
Practice Address - Fax:317-477-6409
Is Sole Proprietor?:No
Enumeration Date:2021-04-15
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN02007088A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program