Provider Demographics
NPI:1770559924
Name:BLAKE, RICHARD LAWRENCE (DPM)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:LAWRENCE
Last Name:BLAKE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 HYDE ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109-4806
Mailing Address - Country:US
Mailing Address - Phone:415-353-6400
Mailing Address - Fax:415-353-6401
Practice Address - Street 1:900 HYDE ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-4806
Practice Address - Country:US
Practice Address - Phone:415-353-6400
Practice Address - Fax:415-353-6401
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2437213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E24370Medicare ID - Type Unspecified
CAT11326Medicare UPIN