Provider Demographics
NPI:1659060713
Name:BLAKE, DAVID ALEJANDRO (LDO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ALEJANDRO
Last Name:BLAKE
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 NW 79TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33147-4600
Mailing Address - Country:US
Mailing Address - Phone:305-913-8714
Mailing Address - Fax:305-691-5760
Practice Address - Street 1:3200 NW 79TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33147-4600
Practice Address - Country:US
Practice Address - Phone:305-913-8714
Practice Address - Fax:305-691-5760
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-04
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO6867156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician