Provider Demographics
NPI:1871817312
Name:BLAKE, PATRICK W (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:W
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 1:501 WASHINGTON ST
Mailing Address - Street 2:SUITE 502
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2231
Mailing Address - Country:US
Mailing Address - Phone:619-542-0013
Mailing Address - Fax:
Practice Address - Street 1:501 WASHINGTON ST
Practice Address - Street 2:SUITE 502
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2231
Practice Address - Country:US
Practice Address - Phone:619-542-0013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-25
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA130951207N00000X
TXP3510207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology