Provider Demographics
NPI:1588855803
Name:BLAKE, MICHAEL TODD (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TODD
Last Name:BLAKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 HOSPITAL PL
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-6999
Mailing Address - Country:US
Mailing Address - Phone:907-714-4444
Mailing Address - Fax:
Practice Address - Street 1:250 HOSPITAL PLACE
Practice Address - Street 2:CENTRAL PENINSULA HOSPITAL
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669
Practice Address - Country:US
Practice Address - Phone:530-208-8388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A11305204R00000X
NVDO1534207P00000X
AK7612207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVDL076ZMedicare PIN