Provider Demographics
NPI:1316921182
Name:BLAKE, DIANE R (MD)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:R
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:DIANE
Other - Middle Name:R
Other - Last Name:BLAKE-JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 62
Mailing Address - Street 2:TURNPIKE STATION
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545-0062
Mailing Address - Country:US
Mailing Address - Phone:508-334-8815
Mailing Address - Fax:508-334-5374
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:DEPARTMENT OF ADOLESCENT MEDICINE
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-856-5624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1544702080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3169863Medicaid
MAF75057Medicare UPIN
MA3169863Medicaid