DR. PERTH AGUSTA BLAKE, M.D. - NPI NUMBER 1063505105

Summary

Provider Name: DR. PERTH AGUSTA BLAKE, M.D.

NPI Number: 1063505105

Clasification: Family Medicine (207Q00000X)

Organization: YOU AND YOUR HEALTH FAMILY CARE INC

Address:
1840 CLASSIQUE LN
TAVARES, FL
ZIP 32778

Phone Number: (352) 508-5046



Detailed Information

DR. Perth Agusta Blake, M.D. is a family physician in Tavares, FL with 21 years of experience. The provider is family Medicine is the medical specialty which is concerned with the total health care of the individual and the family. It is the specialty in breadth which integrates the biological, clinical, and behavioral sciences. The scope of family medicine is not limited by age, sex, organ system, or disease entity. The assigned NPI number for this provider is 1063505105 and is registered as an individual entity type.

The NPPES NPI record indicates the provider is a male.

Education
Medical School: LOMA LINDA UNIVERSITY SCHOOL OF MEDICINE
Graduation Year: 1993

The provider's business address is:

1840 CLASSIQUE LN
TAVARES, FL
ZIP 32778-748
Phone: (352) 508-5046
Fax: (352) 508-5048

The enumeration date for this NPI number is 10/2/2006 and was last updated on 3/16/2012.

Map - Location of Practice

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Taxonomy Codes

The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1 207Q00000X Family Medicine ME0069890 FL Yes

Other (Legacy) Identifiers

The following legacy identifiers are available for this provider:

No. Other Provider Identifier Other Provider Identifier Type Other Provider Identifier State Other Provider Identifier Issuer
1 255623500 MEDICAID FL
2 31711Y OTHER FL MEDICARE ID
3 G31272 MEDICARE UPIN FL

NPI Record

No. Field Name Field Value
1 NPI 1063505105
2 Entity Type Code 1
3 Provider Last Name Legal Name BLAKE
4 Provider First Name PERTH
5 Provider Middle Name AGUSTA
6 Provider Name Prefix Text DR.
7 Provider Credential Text M.D.
8 Provider First Line Business Practice Location Address 1840 CLASSIQUE LN
9 Provider Business Practice Location Address City Name TAVARES
10 Provider Business Practice Location Address State Name FL
11 Provider Business Practice Location Address Postal Code 327785748
12 Provider Business Practice Location Address Country Code If outside U S US
13 Provider Business Practice Location Address Telephone Number 3525085046
14 Provider Business Practice Location Address Fax Number 3525085048
15 Provider Enumeration Date 10/2/2006
16 Last Update Date 3/16/2012
17 Provider Gender Code M
18 Healthcare Provider Taxonomy Code 1 207Q00000X
19 Provider License Number 1 ME0069890
20 Provider License Number State Code 1 FL
21 Healthcare Provider Primary Taxonomy Switch 1 Y
22 Other Provider Identifier 1 255623500
23 Other Provider Identifier Type Code 1 05
24 Other Provider Identifier State 1 FL
25 Other Provider Identifier 2 31711Y
26 Other Provider Identifier Type Code 2 01
27 Other Provider Identifier State 2 FL
28 Other Provider Identifier Issuer 2 MEDICARE ID
29 Other Provider Identifier 3 G31272
30 Other Provider Identifier Type Code 3 02
31 Other Provider Identifier State 3 FL
32 Is Sole Proprietor Y

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This page was last updated on: 3/11/2014
All materials and services on this site are provided on an "as is" and "as available" basis without warranty of any kind. The NPI record is maintained by the National Plan & Provider Enumeration System (NPPES) and anyone may request this information and other NPPES health care provider data from HHS under The Freedom of Information Act (FOIA), Title 5 of the United States Code, section 552. To update the NPI records please contact the NPPES.