Provider Demographics
NPI:1235323759
Name:TARR, BLAKE W (OD)
Entity type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:W
Last Name:TARR
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 766
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37760-0766
Mailing Address - Country:US
Mailing Address - Phone:865-475-6565
Mailing Address - Fax:
Practice Address - Street 1:555 W HIGHWAY 11E
Practice Address - Street 2:
Practice Address - City:NEW MARKET
Practice Address - State:TN
Practice Address - Zip Code:37820-4305
Practice Address - Country:US
Practice Address - Phone:865-475-6565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-28
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2482152W00000X, 152WC0802X, 152WP0200X, 152WS0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5176410001Medicare NSC
TNU96403Medicare UPIN
TN3945948Medicare PIN