Provider Demographics
NPI:1447588280
Name:BLAKE D. ALEXANDER, MD PC
Entity Type:Organization
Organization Name:BLAKE D. ALEXANDER, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:D
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-578-5072
Mailing Address - Street 1:1101 STANDIFORD AVE
Mailing Address - Street 2:SUITE A-3
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-0982
Mailing Address - Country:US
Mailing Address - Phone:209-578-5072
Mailing Address - Fax:209-578-5292
Practice Address - Street 1:1101 STANDIFORD AVE
Practice Address - Street 2:SUITE A-3
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-0982
Practice Address - Country:US
Practice Address - Phone:209-578-5072
Practice Address - Fax:209-578-5292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-04
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC52849207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty