Provider Demographics
NPI:1881616191
Name:BLAKE, JAMES DAVIS (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:DAVIS
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 1:3081 LORNA RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35216-4579
Mailing Address - Country:US
Mailing Address - Phone:205-979-3381
Mailing Address - Fax:
Practice Address - Street 1:3081 LORNA RD
Practice Address - Street 2:SUITE 101
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35216-4579
Practice Address - Country:US
Practice Address - Phone:205-979-3381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL8072207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009936823Medicaid
AL515-00146OtherBLUE CROSS OF AL
AL009936823Medicaid
AL515-00146OtherBLUE CROSS OF AL