Provider Demographics
NPI:1104883123
Name:BLAKE, DOUGLAS (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:BLAKE
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 1:690 CANTON ST
Mailing Address - Street 2:STE 325
Mailing Address - City:WESTWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02090-2324
Mailing Address - Country:US
Mailing Address - Phone:781-407-7713
Mailing Address - Fax:781-407-0998
Practice Address - Street 1:591 EDDY ST
Practice Address - Street 2:DEPT OF ANESTHESIA
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4922
Practice Address - Country:US
Practice Address - Phone:401-444-2284
Practice Address - Fax:401-444-5083
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RIRI8815207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIDB12516Medicaid
RI007004531Medicare ID - Type UnspecifiedPROVIDER NUMBER
RIDB12516Medicaid