Blake, Diane R
Blake, Diane R is an individual health care provider with primary practice located at 55 Lake Ave N Department Of Adolescent Medicine, Worcester MA 01655-0002. She recently has only one registered license in Allopathic & Osteopathic Physicians / Adolescent Medicine, which is considered as her primary health care specialty. Blake, Diane R can be contacted via phone (508) 856-5624.Contact Information
Primary practice address
55 Lake Ave N Department Of Adolescent Medicine
Worcester MA 01655-0002
Phone: (508) 856-5624
Fax:
Website:
Health care specialties
| Specialty | Code | License # | State |
|---|---|---|---|
| Allopathic & Osteopathic Physicians / Adolescent Medicine | 2080A0000X | 154470 | Massachusetts |
Profile Details
| NPI number | 1316921182 |
|---|---|
| LBN Legal business name | Blake, Diane R |
| Credentials | Doctor of Medicine (MD) |
| Entity | Individual |
| Sole proprietor 1 | No |
| Enumeration date | Dec 5th, 2005 |
| Last updated | Nov 10th, 2020 - about 4 years ago |
1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.
Identifiers
| State | Type | Number | Issuer |
|---|---|---|---|
| All States | NPI | 1316921182 | NPPES |
| Massachusetts | MEDICAID | 3169863 |
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