Provider Demographics
NPI:1497738439
Name:BLAKE, GARY DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:DAVID
Last Name:BLAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8010 FROST ST
Mailing Address - Street 2:SUITE 402
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-2778
Mailing Address - Country:US
Mailing Address - Phone:858-565-8100
Mailing Address - Fax:858-565-8200
Practice Address - Street 1:8010 FROST ST
Practice Address - Street 2:SUITE 402
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2778
Practice Address - Country:US
Practice Address - Phone:858-565-8100
Practice Address - Fax:858-565-8200
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-23
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG44807207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG448070Medicare ID - Type UnspecifiedPPIN