Provider Demographics
NPI:1447226055
Name:BLAKE, RANDALL CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:CHARLES
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 1:1329 LUSITANA ST
Mailing Address - Street 2:SUITE 602
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-2429
Mailing Address - Country:US
Mailing Address - Phone:808-522-5055
Mailing Address - Fax:808-524-6306
Practice Address - Street 1:1329 LUSITANA ST
Practice Address - Street 2:SUITE 602
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2429
Practice Address - Country:US
Practice Address - Phone:808-522-5055
Practice Address - Fax:808-524-6306
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI14192208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100171930AMedicaid
IN100171930AMedicaid
INE03771Medicare UPIN