Provider Demographics
NPI:1801935283
Name:RICHARDSON, BLAKE MARTIN (DC)
Entity type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:MARTIN
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:9601 PULASKI PARK DR
Mailing Address - Street 2:SUITE 416
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-1409
Mailing Address - Country:US
Mailing Address - Phone:410-933-5678
Mailing Address - Fax:
Practice Address - Street 1:8555 16TH ST
Practice Address - Street 2:SUITE 602
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-2816
Practice Address - Country:US
Practice Address - Phone:240-863-3526
Practice Address - Fax:240-863-3680
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS01745111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor