Provider Demographics
NPI:1659364016
Name:BLAKE, PAUL ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:ANTHONY
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 1:123 N CENTENNIAL WAY
Mailing Address - Street 2:STE 252
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-6693
Mailing Address - Country:US
Mailing Address - Phone:480-834-8802
Mailing Address - Fax:480-834-8448
Practice Address - Street 1:123 N CENTENNIAL WAY
Practice Address - Street 2:STE 252
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-6693
Practice Address - Country:US
Practice Address - Phone:480-834-8802
Practice Address - Fax:480-834-8448
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14159208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ230673Medicaid
AZMD14159Medicare PIN
AZD43710Medicare UPIN