Provider Demographics
NPI:1023049335
Name:BLAKE, ROGER ALAN (MD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:ALAN
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 1:907 E SUNFLOWER RD
Mailing Address - Street 2:101
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-2830
Mailing Address - Country:US
Mailing Address - Phone:662-846-8880
Mailing Address - Fax:662-846-8886
Practice Address - Street 1:907 E SUNFLOWER RD
Practice Address - Street 2:101
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2830
Practice Address - Country:US
Practice Address - Phone:662-846-8880
Practice Address - Fax:662-846-8886
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16881174400000X
IDMC-26702086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00122620Medicaid
7887026OtherAETNA
7887026OtherAETNA
MSC03406Medicare ID - Type Unspecified