Provider Demographics
NPI:1033132170
Name:ALEXANDER, BLAKE DANIEL (MD)
Entity Type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:DANIEL
Last Name:ALEXANDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 STANDIFORD AVE
Mailing Address - Street 2:SUITE A-3
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-0982
Mailing Address - Country:US
Mailing Address - Phone:209-578-5072
Mailing Address - Fax:209-578-5292
Practice Address - Street 1:1101 STANDIFORD AVE
Practice Address - Street 2:SUITE A-3
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-0982
Practice Address - Country:US
Practice Address - Phone:209-578-5072
Practice Address - Fax:209-578-5292
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC52849207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ48224ZOtherMEDICARE IDENTIFICATION #