Provider Demographics
NPI:1003835539
Name:BLAKE, HERBERT ALDEN (OD)
Entity Type:Individual
Prefix:DR
First Name:HERBERT
Middle Name:ALDEN
Last Name:BLAKE
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 1:12914 130TH AVENUE CT E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-4825
Mailing Address - Country:US
Mailing Address - Phone:253-840-0780
Mailing Address - Fax:
Practice Address - Street 1:OPTOMETRY CLINIC
Practice Address - Street 2:MADIGAN ARMY MEDICAL CENTER
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-968-2790
Practice Address - Fax:253-968-4677
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA953152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist