Provider Demographics
NPI:1467030858
Name:BLAKE, MALCOLM HOSAIN (MD)
Entity type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:HOSAIN
Last Name:BLAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 E TACHEVAH DR STE 2E107
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-5752
Mailing Address - Country:US
Mailing Address - Phone:760-561-7373
Mailing Address - Fax:
Practice Address - Street 1:1150 N PALM CANYON DR OFC
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-4402
Practice Address - Country:US
Practice Address - Phone:760-561-7344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA192845207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program