Healthcare Provider Details

I. General information

NPI: 1528025749
Provider Name (Legal Business Name): MEGHAN E BLAKE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 10/28/2022
Certification Date: 10/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 BLAKE AVE
GLENWOOD SPRINGS CO
81601-4227
US

IV. Provider business mailing address

4100 GUARDIAN ST STE 205
SIMI VALLEY CA
93063-6721
US

V. Phone/Fax

Practice location:
  • Phone: 970-447-4065
  • Fax:
Mailing address:
  • Phone: 855-504-4544
  • Fax: 805-577-2018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberA98185
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number227414
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA98185
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: