Healthcare Provider Details

I. General information

NPI: 1447588280
Provider Name (Legal Business Name): BLAKE D. ALEXANDER, MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2009
Last Update Date: 12/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 STANDIFORD AVE SUITE A-3
MODESTO CA
95350-0982
US

IV. Provider business mailing address

1101 STANDIFORD AVE SUITE A-3
MODESTO CA
95350-0982
US

V. Phone/Fax

Practice location:
  • Phone: 209-578-5072
  • Fax: 209-578-5292
Mailing address:
  • Phone: 209-578-5072
  • Fax: 209-578-5292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberC52849
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberC52849
License Number StateCA

VIII. Authorized Official

Name: BLAKE D. ALEXANDER
Title or Position: OWNER
Credential: M.D.
Phone: 209-578-5072