Healthcare Provider Details

I. General information

NPI: 1821380387
Provider Name (Legal Business Name): RICHARD E BLAKE MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2011
Last Update Date: 05/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 SPRING ST SUITE 300
SILVER SPRING MD
20910-4003
US

IV. Provider business mailing address

8214 TUCKERMAN LN
POTOMAC MD
20854-3744
US

V. Phone/Fax

Practice location:
  • Phone: 301-608-9480
  • Fax: 301-608-9088
Mailing address:
  • Phone: 301-983-9366
  • Fax: 301-983-3283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License NumberD30235
License Number StateMD

VIII. Authorized Official

Name: DR. RICHARD ENRIQUE BLAKE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 301-983-9366