Provider Demographics
NPI:1639109267
Name:BLAKE, HEIDI C (MD)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:C
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 ALUMNI DR
Mailing Address - Street 2:
Mailing Address - City:EXETER
Mailing Address - State:NH
Mailing Address - Zip Code:03833-2128
Mailing Address - Country:US
Mailing Address - Phone:603-580-6793
Mailing Address - Fax:603-580-7006
Practice Address - Street 1:5 ALUMNI DR
Practice Address - Street 2:
Practice Address - City:EXETER
Practice Address - State:NH
Practice Address - Zip Code:03833-2128
Practice Address - Country:US
Practice Address - Phone:603-580-6793
Practice Address - Fax:603-580-7006
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME014658207PE0004X
NH15691207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
G64000Medicare UPIN
MEMM7123Medicare ID - Type Unspecified