Provider Demographics
NPI:1962481929
Name:BLAKE, GERARD FRANCIS (MD)
Entity Type:Individual
Prefix:
First Name:GERARD
Middle Name:FRANCIS
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 1:525 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-5616
Mailing Address - Country:US
Mailing Address - Phone:858-499-2777
Mailing Address - Fax:619-585-4005
Practice Address - Street 1:525 3RD AVE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-5616
Practice Address - Country:US
Practice Address - Phone:858-499-2777
Practice Address - Fax:619-585-4005
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21229207Q00000X
CAC53165207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC212291Medicaid
SCAA16155004Medicare UPIN
SCAA16156795Medicare UPIN
SCAA16155551Medicare PIN
SC1497874424Medicare PIN
SC212291Medicaid