Provider Demographics
NPI:1326000894
Name:BLAKE, HU AL II (MD)
Entity Type:Individual
Prefix:DR
First Name:HU
Middle Name:AL
Last Name:BLAKE
Suffix:II
Gender:M
Credentials:MD
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Mailing Address - Street 1:1200 N BEAVER ST
Mailing Address - Street 2:PAYER CREDENTIALING
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3118
Mailing Address - Country:US
Mailing Address - Phone:928-773-2559
Mailing Address - Fax:928-213-6292
Practice Address - Street 1:199 S CANDY LN
Practice Address - Street 2:SUITE 1A
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4183
Practice Address - Country:US
Practice Address - Phone:928-649-7969
Practice Address - Fax:928-634-7921
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2017-03-14
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Provider Licenses
StateLicense IDTaxonomies
AZ29975208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ636128Medicaid
AZZ69115Medicare PIN
AZ636128Medicaid