Provider Demographics
NPI:1831100502
Name:BLAKE, WILLIAM J (DPM)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:J
Last Name:BLAKE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2019 GALISTEO ST STE K
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-2159
Mailing Address - Country:US
Mailing Address - Phone:505-982-0123
Mailing Address - Fax:505-982-5714
Practice Address - Street 1:2019 GALISTEO ST STE K
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-2159
Practice Address - Country:US
Practice Address - Phone:505-982-0123
Practice Address - Fax:505-982-5714
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM280213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM005445OtherBLUE CROSS BLUE SHIELD
NMPROVP11835OtherMOLINA
NM75222353Medicaid
NM201035866OtherPRESBYTERIAN HP
NMP00414656OtherRAILROAD MEDICARE
NMP00414656OtherRAILROAD MEDICARE
U89226Medicare UPIN