Healthcare Provider Details

I. General information

NPI: 1831161264
Provider Name (Legal Business Name): MICHAEL G BLAKE O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 12/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 W COAL AVE
GALLUP NM
87301-6206
US

IV. Provider business mailing address

124 W COAL AVE
GALLUP NM
87301-6206
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-2020
  • Fax: 505-863-2204
Mailing address:
  • Phone: 505-722-2020
  • Fax: 505-863-2204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2241
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2241
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number2241
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number2241
License Number StateNM
# 5
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number2241
License Number StateNM
# 6
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number2241
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: