Provider Demographics
NPI:1831161348
Name:BLAKE, DAVID (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
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 1:100-15TH AVE
Mailing Address - Street 2:STE 180
Mailing Address - City:SOUTH MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53172-1160
Mailing Address - Country:US
Mailing Address - Phone:414-827-2959
Mailing Address - Fax:262-827-2948
Practice Address - Street 1:14555 W NATIONAL AVE
Practice Address - Street 2:STE 192
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-4494
Practice Address - Country:US
Practice Address - Phone:262-827-2959
Practice Address - Fax:262-827-2948
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2013-03-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI19654207RH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI02120-0262Medicare PIN
WI68015-0070Medicare PIN