Provider Demographics
NPI:1104262930
Name:BLAKE, ROBERT ALEXANDER
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:ALEXANDER
Last Name:BLAKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 NUUANU AVE
Mailing Address - Street 2:1309
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-4017
Mailing Address - Country:US
Mailing Address - Phone:214-514-9091
Mailing Address - Fax:
Practice Address - Street 1:1255 NUUANU AVE
Practice Address - Street 2:1309
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-4017
Practice Address - Country:US
Practice Address - Phone:214-514-9091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-20
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program