Healthcare Provider Details

I. General information

NPI: 1477541043
Provider Name (Legal Business Name): ROBERT FLAKE DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

728 E WHITE MOUNTAIN BLVD SUITE C
PINETOP AZ
85935-7027
US

IV. Provider business mailing address

PO BOX 430D
PINETOP AZ
85935-0416
US

V. Phone/Fax

Practice location:
  • Phone: 928-367-3701
  • Fax: 928-367-0801
Mailing address:
  • Phone: 928-367-3701
  • Fax: 928-367-0801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number0105
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: