Provider Demographics
NPI:1992792980
Name:BLAKE, JEFFREY D (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:D
Last Name:BLAKE
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 1:250 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:GARDNER
Mailing Address - State:MA
Mailing Address - Zip Code:01440-1396
Mailing Address - Country:US
Mailing Address - Phone:978-630-5050
Mailing Address - Fax:978-630-5059
Practice Address - Street 1:250 GREEN ST
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:MA
Practice Address - Zip Code:01440-1396
Practice Address - Country:US
Practice Address - Phone:978-630-5050
Practice Address - Fax:978-630-5059
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA78308207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3118223Medicaid
MAJ12461Medicare ID - Type Unspecified
MA3118223Medicaid