Provider Demographics
NPI:1043209331
Name:BLAKE, DOREEN (MD)
Entity Type:Individual
Prefix:DR
First Name:DOREEN
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
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:P.O. BOX 12622
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4017
Mailing Address - Country:US
Mailing Address - Phone:443-481-6580
Mailing Address - Fax:443-481-6515
Practice Address - Street 1:1450 MERCANTILE LN
Practice Address - Street 2:SUITE 111
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-5376
Practice Address - Country:US
Practice Address - Phone:301-925-7610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD39421207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD116600000Medicaid
P01298022OtherRR MEDICARE
MD116600000Medicaid
P01298022OtherRR MEDICARE
G00048Medicare PIN