1831100502 NPI number — DR. WILLIAM J BLAKE DPM

Table of content: DR. WILLIAM J BLAKE DPM (NPI 1831100502)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831100502 NPI number — DR. WILLIAM J BLAKE DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAKE
Provider First Name:
WILLIAM
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831100502
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/14/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2019 GALISTEO ST STE K
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA FE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87505-2159
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-982-0123
Provider Business Mailing Address Fax Number:
505-982-5714

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2019 GALISTEO ST STE K
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA FE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87505-2159
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-982-0123
Provider Business Practice Location Address Fax Number:
505-982-5714
Provider Enumeration Date:
08/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  280 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NM005445 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: PROVP11835 . This is a "MOLINA" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 75222353 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201035866 . This is a "PRESBYTERIAN HP" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: P00414656 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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