1811963705 NPI number — DR. SUSAN F BLAKE OD

Table of content: DR. SUSAN F BLAKE OD (NPI 1811963705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811963705 NPI number — DR. SUSAN F BLAKE OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAKE
Provider First Name:
SUSAN
Provider Middle Name:
F
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811963705
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
313 LINWOOD AVE NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44708-5624
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-455-2348
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2216 LINCOLN WAY E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MASSILLON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44646-7062
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-832-9966
Provider Business Practice Location Address Fax Number:
330-832-6007
Provider Enumeration Date:
02/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  5196 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 51108 . This is a "DAVIS VISION" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2601081 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 311529091 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 22683 . This is a "NVA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 27426 . This is a "SPECTERA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: OH5196 . This is a "EYEMED" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 202699359 . This is a "VSP" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 202699359 . This is a "TRICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 311529091 . This is a "PCM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: OH00213 . This is a "VBA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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