Individual
DR. JOHN S BLAKE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
210 W 300 N 7-3, ROOSEVELT, UT 84066
(435) 722-3971
(435) 722-6104
Mailing address
210 W 300 N 7-3, ROOSEVELT, UT 84066
(435) 722-3971
(435) 722-6104
Taxonomy
Speciality
Code
Description
License number
State
207ND0101X
MOHS-Micrographic Surgery Physician
Primary
49109901205
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
D3948
—
UT
Enumeration date
03/24/2006
Last updated
05/02/2017
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