Individual
DR. BLAKE JEFFREY ILLSTON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
300 W HOSPITAL RD, FORT GORDON, GA 30905-5741
(706) 787-9285
Mailing address
300 W HOSPITAL RD, FORT GORDON, GA 30905-5741
(706) 787-9285
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
68035
GA
207PE0004X
Emergency Medical Services (Emergency Medicine) Physician
RTP001882
GA
Other
Enumeration date
05/02/2007
Last updated
03/29/2023
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