1578676714 NPI number — DR. DUDLEY DAVID BLAKE PH.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578676714 NPI number — DR. DUDLEY DAVID BLAKE PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAKE
Provider First Name:
DUDLEY
Provider Middle Name:
DAVID
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
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:
1578676714
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
701 E JEFFERSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83712-6413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-336-0461
Provider Business Mailing Address Fax Number:
208-422-1164

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BOISE VA MEDICAL CENTER
Provider Second Line Business Practice Location Address:
500 WEST FORT STREET
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83701-4598
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-422-1125
Provider Business Practice Location Address Fax Number:
208-422-1164
Provider Enumeration Date:
08/15/2006

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: 103TC0700X , with the licence number:  PSY313 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PSY313 . This is a "STATE PSYCHOLOGY LICENSE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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