Provider Demographics
NPI:1477541043
Name:FLAKE, ROBERT (DPM)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:FLAKE
Suffix:
Gender:M
Credentials:DPM
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 430D
Mailing Address - Street 2:
Mailing Address - City:PINETOP
Mailing Address - State:AZ
Mailing Address - Zip Code:85935-0416
Mailing Address - Country:US
Mailing Address - Phone:928-367-3701
Mailing Address - Fax:928-367-0801
Practice Address - Street 1:728 E WHITE MOUNTAIN BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:PINETOP
Practice Address - State:AZ
Practice Address - Zip Code:85935-7027
Practice Address - Country:US
Practice Address - Phone:928-367-3701
Practice Address - Fax:928-367-0801
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0105213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ700519Medicaid
AZDPM105Medicare ID - Type Unspecified
AZT41607Medicare UPIN