Provider Demographics
NPI:1205822665
Name:BLAKE, DANIEL R (DO)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:R
Last Name:BLAKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:9127 W RUSSELL RD STE 110
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-1253
Mailing Address - Country:US
Mailing Address - Phone:702-878-0070
Mailing Address - Fax:702-209-2064
Practice Address - Street 1:9127 W RUSSELL RD STE 110
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148
Practice Address - Country:US
Practice Address - Phone:702-878-0070
Practice Address - Fax:702-209-2064
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1224207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100506317Medicaid
NVP00226099Medicare PIN