Provider Demographics
NPI:1396159620
Name:BLAKE, DANIELLE (MD)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:741 NORTHFIELD AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-1104
Mailing Address - Country:US
Mailing Address - Phone:973-243-0600
Mailing Address - Fax:973-243-0707
Practice Address - Street 1:741 NORTHFIELD AVE STE 104
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-1104
Practice Address - Country:US
Practice Address - Phone:973-243-1486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-14
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10613900174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist