Provider Demographics
NPI:1699278952
Name:BLAKE, MATTHEW ALEXANDER (IDC)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:ALEXANDER
Last Name:BLAKE
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1336 BRUNNER ST APT H
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-1690
Mailing Address - Country:US
Mailing Address - Phone:931-865-6165
Mailing Address - Fax:
Practice Address - Street 1:1336 BRUNNER ST APT H
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-1690
Practice Address - Country:US
Practice Address - Phone:931-865-6165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman