Provider Demographics
NPI:1447550082
Name:TISHMAN, BLAKE (DC)
Entity type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:
Last Name:TISHMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8177 GLADES RD STE 24
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33434-4063
Mailing Address - Country:US
Mailing Address - Phone:561-487-7200
Mailing Address - Fax:561-487-7229
Practice Address - Street 1:750 E SAMPLE RD STE 3-4
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33064-5138
Practice Address - Country:US
Practice Address - Phone:561-576-7740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-29
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 10137111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLEY351ZMedicare PIN