Healthcare Provider Details

I. General information

NPI: 1386645224
Provider Name (Legal Business Name): CHARLES RICHARD BLAKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 06/01/2020
Certification Date: 06/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-0371
US

IV. Provider business mailing address

PO BOX 100284
GAINESVILLE FL
32610-0284
US

V. Phone/Fax

Practice location:
  • Phone: 352-392-3451
  • Fax:
Mailing address:
  • Phone: 352-273-8778
  • Fax: 352-273-7402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number29828
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME90057
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: