Provider Demographics
NPI:1063484210
Name:BLAKE, DAVID PAUL (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:PAUL
Last Name:BLAKE
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 37174
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3174
Mailing Address - Country:US
Mailing Address - Phone:571-423-5699
Mailing Address - Fax:571-423-5698
Practice Address - Street 1:3300 GALLOWS RD
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-3307
Practice Address - Country:US
Practice Address - Phone:703-531-2246
Practice Address - Fax:703-237-7895
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0938952086S0102X, 2086S0127X
CT61499208600000X, 2086S0102X, 2086S0127X
VA01012416162086S0102X, 2086S0127X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA488414OtherANTHEM BC/BS
VAPAROtherMULTIPLAN
VAPAROtherCIGNA
VA1063484210OtherUNITED HEALTHCARE
VA1063484210OtherCOVENTRY HEALTH NETWORK
VAPAROtherCORVEL
VA10106541OtherOPTIMA HEALTH
VA1063484210Medicaid
VAPAROtherUSA MANAGED CARE
NC1063484210Medicaid
VAPAROtherVIRGINIA HEALTH NETWORK
VAPAROtherAETNA
VA10106541OtherOPTIMA HEALTH
VAP01262072Medicare PIN