Basic Information
| Provider Information | |||||||||
| NPI: | 1104883123 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAKE | ||||||||
| FirstName: | DOUGLAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 690 CANTON ST | ||||||||
| Address2: | STE 325 | ||||||||
| City: | WESTWOOD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020902324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7814077713 | ||||||||
| FaxNumber: | 7814070998 | ||||||||
| Practice Location | |||||||||
| Address1: | 591 EDDY ST | ||||||||
| Address2: | DEPT OF ANESTHESIA | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014442284 | ||||||||
| FaxNumber: | 4014445083 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 04/15/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | RI8815 | RI | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | DB12516 | 05 | RI | MEDICAID |