Provider Demographics
NPI:1851362792
Name:BLAKE, CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:BLAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6565 E CARONDELET DR STE 155
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-3587
Mailing Address - Country:US
Mailing Address - Phone:520-849-8900
Mailing Address - Fax:520-849-7137
Practice Address - Street 1:6565 E CARONDELET DR STE 155
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710
Practice Address - Country:US
Practice Address - Phone:520-849-8900
Practice Address - Fax:520-849-7137
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ19358208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZE85976Medicare UPIN
AZZ25WCHRM03Medicare ID - Type Unspecified