Provider Demographics
NPI:1366470148
Name:BLAKE, PAUL MAXWELL III (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:MAXWELL
Last Name:BLAKE
Suffix:III
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:PO BOX 88
Mailing Address - Street 2:5 E ALVON ROAD SUITE 7
Mailing Address - City:WHITE SULPHUR SPRINGS
Mailing Address - State:WV
Mailing Address - Zip Code:24986-2373
Mailing Address - Country:US
Mailing Address - Phone:304-536-5030
Mailing Address - Fax:304-536-5031
Practice Address - Street 1:2900 1ST AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702-1241
Practice Address - Country:US
Practice Address - Phone:304-399-7484
Practice Address - Fax:304-399-7579
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD429954207R00000X
WV20938207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA105606OtherMEDICARE
OH2341602Medicaid
WV181232700Medicaid
PA1017240800001Medicaid
PA1896405OtherHIGHMARK
KY64073695Medicaid
KY64073695Medicaid
PA1017240800001Medicaid