Provider Demographics
NPI:1932194784
Name:BLAKE, CARSON CURTIS (MD)
Entity Type:Individual
Prefix:DR
First Name:CARSON
Middle Name:CURTIS
Last Name:BLAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:C.
Other - Middle Name:CURTIS
Other - Last Name:BLAKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:305 N. MAIN
Mailing Address - Street 2:
Mailing Address - City:ENNIS
Mailing Address - State:MT
Mailing Address - Zip Code:59729
Mailing Address - Country:US
Mailing Address - Phone:406-682-6862
Mailing Address - Fax:
Practice Address - Street 1:305 N. MAIN
Practice Address - Street 2:
Practice Address - City:ENNIS
Practice Address - State:MT
Practice Address - Zip Code:59729
Practice Address - Country:US
Practice Address - Phone:406-682-6862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT7066207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0042109Medicaid
MT0042109Medicaid
MT000082367Medicare ID - Type UnspecifiedMC INDIVIDUAL PROVIDER #
MTC13518Medicare UPIN