Healthcare Provider Details

I. General information

NPI: 1104883123
Provider Name (Legal Business Name): DOUGLAS BLAKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 04/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

591 EDDY ST DEPT OF ANESTHESIA
PROVIDENCE RI
02903-4922
US

IV. Provider business mailing address

690 CANTON ST STE 325
WESTWOOD MA
02090-2324
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-2284
  • Fax: 401-444-5083
Mailing address:
  • Phone: 781-407-7713
  • Fax: 781-407-0998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberRI8815
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: