Provider Demographics
NPI:1861424004
Name:BLAKE, LISA (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BLAKE
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 1:15 RIVERBEND DR SW
Mailing Address - Street 2:STE 200
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-6065
Mailing Address - Country:US
Mailing Address - Phone:706-291-0884
Mailing Address - Fax:706-235-0405
Practice Address - Street 1:15 RIVERBEND DR SW
Practice Address - Street 2:STE 200
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-6065
Practice Address - Country:US
Practice Address - Phone:706-291-0884
Practice Address - Fax:706-235-0405
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055101207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA305104628AMedicaid
GAI56077Medicare UPIN