Provider Demographics
NPI:1548263064
Name:BLAKE, WYATT KENNY (MD)
Entity type:Individual
Prefix:DR
First Name:WYATT
Middle Name:KENNY
Last Name:BLAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 BOULDER DR
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:GA
Mailing Address - Zip Code:31032-6141
Mailing Address - Country:US
Mailing Address - Phone:478-621-2100
Mailing Address - Fax:478-744-0481
Practice Address - Street 1:1005 BOULDER DR
Practice Address - Street 2:
Practice Address - City:GRAY
Practice Address - State:GA
Practice Address - Zip Code:31032
Practice Address - Country:US
Practice Address - Phone:478-621-2100
Practice Address - Fax:478-744-0481
Is Sole Proprietor?:No
Enumeration Date:2005-05-30
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047702207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000909114EMedicaid
GA843785OtherBCBS OF GEORGIA
GA080176614OtherRAILROAD MEDICARE
GA047702OtherGA LICENSE
GA000909114EMedicaid
GA080176614OtherRAILROAD MEDICARE