Provider Demographics
NPI:1386645224
Name:BLAKE, CHARLES RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:RICHARD
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:PO BOX 100284
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0284
Mailing Address - Country:US
Mailing Address - Phone:352-273-8778
Mailing Address - Fax:352-273-7402
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-0371
Practice Address - Country:US
Practice Address - Phone:352-392-3451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29828207W00000X
FLME90057207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC32840OtherOPTICARE
NC0800815OtherUNITED HEALTHCARE
NC0800815OtherMAMSI
NC806940OtherCOMMUNITY EYE CARE
SCGP4696Medicaid
FL010129300Medicaid
NC5902230Medicaid
NC806940OtherPARTNERS
NC183075OtherMEDCOST
NC141A6OtherBCBS NC
NCOPH174OtherPRIMAHEALTH
NC7273542OtherAETNA
NC141A6OtherBCBS NC
NC183075OtherMEDCOST
NCOPH174OtherPRIMAHEALTH
NC5902230Medicaid
FL37947YMedicare PIN