Healthcare Provider Details

I. General information

NPI: 1639799158
Provider Name (Legal Business Name): PAUL A BLAKE IV DO (AS OF 5/31/2020)
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2020
Last Update Date: 10/01/2021
Certification Date: 10/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 ARNOLD DR
LITTLE ROCK AFB AR
72099-4933
US

IV. Provider business mailing address

1090 ARNOLD DR
LITTLE ROCK AFB AR
72099-4933
US

V. Phone/Fax

Practice location:
  • Phone: 501-987-7319
  • Fax:
Mailing address:
  • Phone: 501-987-7319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number2470
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: