Basic Information
| Provider Information | |||||||||
| NPI: | 1063484210 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAKE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | PAUL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 37174 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212973174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5714235699 | ||||||||
| FaxNumber: | 5714235698 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 GALLOWS RD | ||||||||
| Address2: | |||||||||
| City: | FALLS CHURCH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220423307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035312246 | ||||||||
| FaxNumber: | 7032377895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 06/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0102X | 35.093895 | OH | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 208600000X | 61499 | CT | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0102X | 61499 | CT | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0102X | 0101241616 | VA | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0127X | 0101241616 | VA | N | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 2086S0127X | 35.093895 | OH | N | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 2086S0127X | 61499 | CT | N | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 208600000X | 0101241616 | VA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 488414 | 01 | VA | ANTHEM BC/BS | OTHER | PAR | 01 | VA | MULTIPLAN | OTHER | PAR | 01 | VA | CIGNA | OTHER | 1063484210 | 01 | VA | UNITED HEALTHCARE | OTHER | 1063484210 | 01 | VA | COVENTRY HEALTH NETWORK | OTHER | PAR | 01 | VA | CORVEL | OTHER | 10106541 | 01 | VA | OPTIMA HEALTH | OTHER | 1063484210 | 05 | VA | MEDICAID | PAR | 01 | VA | USA MANAGED CARE | OTHER | 1063484210 | 05 | NC | MEDICAID | PAR | 01 | VA | VIRGINIA HEALTH NETWORK | OTHER | PAR | 01 | VA | AETNA | OTHER |