Provider Demographics
NPI:1831161264
Name:BLAKE, MICHAEL G (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:G
Last Name:BLAKE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 W COAL AVE
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-6206
Mailing Address - Country:US
Mailing Address - Phone:505-722-2020
Mailing Address - Fax:505-863-2204
Practice Address - Street 1:124 W COAL AVE
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-6206
Practice Address - Country:US
Practice Address - Phone:505-722-2020
Practice Address - Fax:505-863-2204
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2241152W00000X, 152WC0802X, 152WL0500X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM00O520OtherBLUE CROSS BLUE SHIELD NM
NM2506478Medicare ID - Type Unspecified
NMT74910Medicare UPIN