Provider Demographics
NPI:1770565657
Name:BLAKE, COLIN (MD)
Entity type:Individual
Prefix:
First Name:COLIN
Middle Name:
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 1:9 GALEN ST STE 130
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-4521
Mailing Address - Country:US
Mailing Address - Phone:617-562-5476
Mailing Address - Fax:
Practice Address - Street 1:200 GROTON RD
Practice Address - Street 2:
Practice Address - City:AYER
Practice Address - State:MA
Practice Address - Zip Code:01432-1168
Practice Address - Country:US
Practice Address - Phone:617-562-5476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA225542207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MABL-A38724Medicare ID - Type Unspecified
MAI33793Medicare UPIN