Provider Demographics
NPI:1528025012
Name:BLAKE, THOMAS DUVALL (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:DUVALL
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 1:7255 HANOVER GREEN DR
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23111-1706
Mailing Address - Country:US
Mailing Address - Phone:804-730-1111
Mailing Address - Fax:804-730-9764
Practice Address - Street 1:7255 HANOVER GREEN DR
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23111-1706
Practice Address - Country:US
Practice Address - Phone:804-730-1111
Practice Address - Fax:804-730-9764
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101034259207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5644097Medicaid
VA5644097Medicaid
080007248Medicare PIN