Provider Demographics
NPI:1861887895
Name:MATESIC, BLAKE
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:MATESIC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2830 VICTORY PKWY
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-1785
Mailing Address - Country:US
Mailing Address - Phone:513-245-3104
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:234 GOODMAN ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2364
Practice Address - Country:US
Practice Address - Phone:513-475-8000
Practice Address - Fax:513-584-0468
Is Sole Proprietor?:No
Enumeration Date:2015-04-06
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH34014033208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program