Provider Demographics
NPI:1538185384
Name:BLAKE-GUMBS, LYLA (MD)
Entity type:Individual
Prefix:
First Name:LYLA
Middle Name:
Last Name:BLAKE-GUMBS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24701 EUCLID AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-1714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-3944
Practice Address - Fax:216-286-6341
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-084366207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000224354OtherUNISON
363362OtherWELLCARE
OHP00333095OtherRAILROAD MEDICARE
OH000000382819OtherANTHEM
OH2472793Medicaid
OH000000530381OtherANTHEM
OH7082178OtherAETNA
OH737670OtherBUCKEYE
363362OtherWELLCARE
OH2472793Medicaid
OHBL4131943Medicare PIN