Provider Demographics
NPI:1982593059
Name:BLAKE, KRISTEN TAYLOR PAIGE (OD)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:TAYLOR PAIGE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3031 TRAYMORE LN
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-2023
Mailing Address - Country:US
Mailing Address - Phone:410-440-6107
Mailing Address - Fax:
Practice Address - Street 1:40 YORK RD STE 500
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-5243
Practice Address - Country:US
Practice Address - Phone:410-616-9952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-02
Last Update Date:2025-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA3089152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist