Provider Demographics
NPI:1295837094
Name:BLAKE, DAVID M (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:M
Last Name:BLAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1221 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2701
Mailing Address - Country:US
Mailing Address - Phone:859-258-6200
Mailing Address - Fax:859-425-4004
Practice Address - Street 1:1221 S BROADWAY # D302
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-2701
Practice Address - Country:US
Practice Address - Phone:859-260-1273
Practice Address - Fax:859-260-7719
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY243572084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64243579Medicaid
D92085Medicare UPIN
KY64243579Medicaid
KY65907768Medicaid
KY0901901Medicare ID - Type Unspecified