Provider Demographics
NPI:1457392938
Name:BLAKE, GERALD ALAN (MD)
Entity Type:Individual
Prefix:
First Name:GERALD
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 1:1694 CACTUS WREN COURT
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-8579
Mailing Address - Country:US
Mailing Address - Phone:909-722-1240
Mailing Address - Fax:
Practice Address - Street 1:1096 CALIMESA BLVD STE D
Practice Address - Street 2:
Practice Address - City:CALIMESA
Practice Address - State:CA
Practice Address - Zip Code:92320-1559
Practice Address - Country:US
Practice Address - Phone:909-722-1240
Practice Address - Fax:909-446-8800
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32432174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A324320Medicaid
CAA26799Medicare UPIN
CA00A324320Medicare ID - Type Unspecified