Provider Demographics
NPI:1811300999
Name:BLAKE, NICHOLAS ZOLTAN (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ZOLTAN
Last Name:BLAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2385 NE HILLTOP LN
Mailing Address - Street 2:
Mailing Address - City:MADRAS
Mailing Address - State:OR
Mailing Address - Zip Code:97741-8733
Mailing Address - Country:US
Mailing Address - Phone:406-258-4789
Mailing Address - Fax:406-258-4732
Practice Address - Street 1:76 NE 12TH ST
Practice Address - Street 2:
Practice Address - City:MADRAS
Practice Address - State:OR
Practice Address - Zip Code:97741-1827
Practice Address - Country:US
Practice Address - Phone:406-258-4789
Practice Address - Fax:406-258-4732
Is Sole Proprietor?:No
Enumeration Date:2014-06-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD184258207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine