Provider Demographics
NPI:1144224817
Name:BLAKE, WILLIAM EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:EDWARD
Last Name:BLAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:298 HENRY CLAY AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70118-5720
Mailing Address - Country:US
Mailing Address - Phone:504-896-9827
Mailing Address - Fax:504-894-5370
Practice Address - Street 1:4740 S I 10 SERVICE RD W
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001-1234
Practice Address - Country:US
Practice Address - Phone:504-883-3703
Practice Address - Fax:504-883-3704
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA011575208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1174891Medicaid