Provider Demographics
NPI:1871101071
Name:LONG, BLAKE ELIZABETH (OD)
Entity type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:ELIZABETH
Last Name:LONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:BLAKE ELIZABETH
Other - Middle Name:NOVY
Other - Last Name:MEANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2547 MACKINNON DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-7903
Mailing Address - Country:US
Mailing Address - Phone:901-258-2800
Mailing Address - Fax:
Practice Address - Street 1:7706 WINCHESTER RD
Practice Address - Street 2:105
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38125
Practice Address - Country:US
Practice Address - Phone:901-752-1551
Practice Address - Fax:901-752-1505
Is Sole Proprietor?:No
Enumeration Date:2020-07-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3623152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist