Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207V00000X | Obstetrician & Gynecologist | 213092-1 | NY |
NPI | 1023036548 |
---|---|
Provider Name | Robert Blake |
First Address | Brooklyn, NY 11212-5539 |
Second Address | Brooklyn, NY 11207 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/07/2006 |
Last Update Date | 23/04/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
01957804 | (05) | NY |
PENDING | (02) |