Provider Demographics
NPI:1811646227
Name:BURCH, BLAKE MICHAEL I (DO)
Entity type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:MICHAEL
Last Name:BURCH
Suffix:I
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1959 NE PACIFIC STREET BOX 357115
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98195-7115
Mailing Address - Country:US
Mailing Address - Phone:206-598-2094
Mailing Address - Fax:206-543-6317
Practice Address - Street 1:1959 NE PACIFIC ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-5156
Practice Address - Country:US
Practice Address - Phone:206-598-2094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-22
Last Update Date:2023-06-08
Deactivation Date:2022-03-30
Deactivation Code:
Reactivation Date:2022-04-18
Provider Licenses
StateLicense IDTaxonomies
FL58876183500000X
WAOL61423697390200000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No183500000XPharmacy Service ProvidersPharmacist