Provider Demographics
NPI:1891790986
Name:BLAKE, TIMOTHY DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DANIEL
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 1:5 COLISEUM AVE
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03063-3292
Mailing Address - Country:US
Mailing Address - Phone:603-882-9800
Mailing Address - Fax:603-882-0556
Practice Address - Street 1:5 COLISEUM AVE
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03063-3292
Practice Address - Country:US
Practice Address - Phone:603-882-9800
Practice Address - Fax:603-882-0556
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA230010207W00000X
NH12643207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3072166Medicaid