Provider Demographics
NPI:1912968744
Name:BLAINE, DAVID ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ALLEN
Last Name:BLAINE
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 1:84 BROOKSHIRE LN
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-6765
Mailing Address - Country:US
Mailing Address - Phone:304-255-2341
Mailing Address - Fax:
Practice Address - Street 1:84 BROOKSHIRE LN
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-6765
Practice Address - Country:US
Practice Address - Phone:304-255-2341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21797207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810001686Medicaid
WVP00186646Medicare PIN
WVBL4151761Medicare ID - Type UnspecifiedMEDICARE PEIN
WV3810001686Medicaid