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DR. WYATT KENNY BLAKE MD

>> Family Medicine >> Allopathic & Osteopathic Physicians

Registrant NPI Number: 1548263064

Individual Registrant:
DR. WYATT KENNY BLAKE MD
Gender: M
Not Sole Proprietor

Location and contact information for practice:
1005 BOULDER DR  GRAY, GA 31032 US
Tel: 478-621-2100  Fax: 478-744-0481

Contact information for business:
1005 BOULDER DR  GRAY, GA 31032-6141 US
Tel: 478-621-2100  Fax: 478-744-0481

Registration Information:
NPI: 1548263064
Entity Type: Individual

Specialty information:

PrimaryCodeCategory/DescriptionStateLicense Number
Y207Q00000XAllopathic & Osteopathic Physicians
Family Medicine
GA047702

Legacy codes, insurance codes and state license numbers:

IssuerNumberStateType
000909114EGA05
GA LICENSE047702GA01
RAILROAD MEDICARE080176614GA01
BCBS OF GEORGIA843785GA01




HEALTH CARE JOBS GA - Page 1



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