Provider Demographics
NPI:1619072212
Name:BLAKE, ROBERT AL (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:AL
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 1:301 GOVERNORS DR SW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-5123
Mailing Address - Country:US
Mailing Address - Phone:256-551-4579
Mailing Address - Fax:256-551-4585
Practice Address - Street 1:301 GOVERNORS DR SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-5123
Practice Address - Country:US
Practice Address - Phone:256-551-4579
Practice Address - Fax:256-551-4585
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD477982080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD255200100Medicaid
MDI13479Medicare UPIN
MDJ179Medicare ID - Type Unspecified