Blake, Diane R

Blake, Diane R is an individual health care provider with primary practice located at 55 Lake Ave N Department Of Adolescent Medicine, Worcester MA 01655-0002. She recently has only one registered license in Allopathic & Osteopathic Physicians / Adolescent Medicine, which is considered as her primary health care specialty. Blake, Diane R can be contacted via phone (508) 856-5624.

Contact Information

Primary practice address
55 Lake Ave N Department Of Adolescent Medicine Worcester MA 01655-0002
Phone: (508) 856-5624
Fax:
Website:
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Health care specialties

SpecialtyCodeLicense #State
Allopathic & Osteopathic Physicians / Adolescent Medicine 2080A0000X 154470 Massachusetts

Profile Details

NPI number 1316921182
LBN Legal business name Blake, Diane R
Credentials Doctor of Medicine (MD)
Entity Individual
Sole proprietor 1 No
Enumeration date Dec 5th, 2005
Last updated Nov 10th, 2020 - about 5 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1316921182 NPPES
Massachusetts MEDICAID 3169863

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