Provider Demographics
NPI:1902134794
Name:BLAKE, CHRISTINA MARISSA (DO)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINA
Middle Name:MARISSA
Last Name:BLAKE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:15717 15 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-2101
Mailing Address - Country:US
Mailing Address - Phone:586-285-3810
Mailing Address - Fax:586-285-3818
Practice Address - Street 1:15717 15 MILE RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035-2101
Practice Address - Country:US
Practice Address - Phone:586-285-3810
Practice Address - Fax:586-285-3818
Is Sole Proprietor?:No
Enumeration Date:2009-12-07
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101018278207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine