Provider Demographics
NPI:1326054255
Name:BLAKE, DAVID ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ALLEN
Last Name:BLAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 S LAKE AVE
Mailing Address - Street 2:535
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-3005
Mailing Address - Country:US
Mailing Address - Phone:626-795-6596
Mailing Address - Fax:626-795-8247
Practice Address - Street 1:225 S LAKE AVE
Practice Address - Street 2:SUITE 535
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-3005
Practice Address - Country:US
Practice Address - Phone:626-795-6596
Practice Address - Fax:626-396-0851
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA77088207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A770880OtherBLUE SHIELD
CA00A770880Medicaid
CAWA77088AMedicare PIN
CA00A770880Medicaid