Provider Demographics
NPI:1255425831
Name:BLAKE, CYNTHEA I (MD, PHD)
Entity type:Individual
Prefix:
First Name:CYNTHEA
Middle Name:I
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2508 E. 11TH AVENUE #301
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206-3234
Mailing Address - Country:US
Mailing Address - Phone:303-394-4344
Mailing Address - Fax:
Practice Address - Street 1:3010 N. CIRCLE DRIVE SUITE 120
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80209
Practice Address - Country:US
Practice Address - Phone:719-264-1500
Practice Address - Fax:719-234-0024
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO302442084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01302447Medicaid
COC9931Medicare ID - Type Unspecified
CO01302447Medicaid