Healthcare Provider Details

I. General information

NPI: 1699702308
Provider Name (Legal Business Name): RICHARD ALAN BLAKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 05/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 HARRODSBURG RD SUITE A-300
LEXINGTON KY
40504-3751
US

IV. Provider business mailing address

PO BOX 936
LONDON KY
40743-0936
US

V. Phone/Fax

Practice location:
  • Phone: 859-276-4429
  • Fax: 859-276-5939
Mailing address:
  • Phone: 606-330-7840
  • Fax: 606-330-7825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number29029
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number29029
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: