Provider Demographics
NPI:1548233125
Name:BLAKE, DAVID P (MD)
Entity Type:Individual
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First Name:DAVID
Middle Name:P
Last Name:BLAKE
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Gender:M
Credentials:MD
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Mailing Address - Street 1:8100 34 AVE S
Mailing Address - Street 2:MAIL STOP 21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1672
Mailing Address - Country:US
Mailing Address - Phone:952-883-5463
Mailing Address - Fax:952-883-8395
Practice Address - Street 1:640 JACKSON STREET
Practice Address - Street 2:MC 11503K
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2502
Practice Address - Country:US
Practice Address - Phone:651-254-3462
Practice Address - Fax:651-254-1603
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
MN259662086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
A95612Medicare UPIN