Provider Demographics
NPI:1417111493
Name:BLAKE, MICHAEL LAURENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LAURENCE
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 1:600 RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5237
Mailing Address - Country:US
Mailing Address - Phone:732-942-5721
Mailing Address - Fax:732-942-5723
Practice Address - Street 1:600 RIVER AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5237
Practice Address - Country:US
Practice Address - Phone:732-942-5721
Practice Address - Fax:732-942-5723
Is Sole Proprietor?:No
Enumeration Date:2008-07-18
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08599800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine