MEDICARE: DR. DOREEN BLAKE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	D39421	MD

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P01298022	OTHER		RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043209331
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DOREEN BLAKE M.D.

Provider Business Mailing Address
First Line	:	P.O. BOX 12622
Second Line	:
City	:	BELFAST
State	:	ME
Zip	:	04915-4017
Country	:	US
Telephone Number	:	443-481-6580
Fax Number	:	443-481-6515

Provider Business Practice Location Address
First Line	:	1450 MERCANTILE LN
Second Line	:	SUITE 111
City	:	LARGO
State	:	MD
Zip	:	20774-5376
Country	:	US
Telephone Number	:	301-925-7610
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2005
Last Update Date	:	06/04/2014

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Directions to “ DR. DOREEN BLAKE M.D.” Practice Location

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