Provider Demographics
NPI:1063474955
Name:BLAKE, MICHAEL CLARENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:CLARENCE
Last Name:BLAKE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2790 GODWIN BLVD
Mailing Address - Street 2:STE 305
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-8151
Mailing Address - Country:US
Mailing Address - Phone:757-934-4222
Mailing Address - Fax:757-934-4111
Practice Address - Street 1:2790 GODWIN BLVD
Practice Address - Street 2:STE 305
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8151
Practice Address - Country:US
Practice Address - Phone:757-934-4222
Practice Address - Fax:757-934-4111
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2012-11-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0101023774208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery