Michael G Blake, O.D.
Individual provider Active NPI Optometrist · Gallup, NM
NPI 1831161264 · NPPES record last updated Dec 11, 2008
Key facts
- NPI
- 1831161264
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Optometrist 152W00000X
- License
- 2241 (NM)
- Practice address
- 124 W Coal Ave
Gallup, NM 87301-6206 - Phone
- (505) 722-2020
- Fax
- (505) 863-2204
- NPI assigned
- Feb 1, 2006
- Sex
- Male
- Sole proprietor
- No
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2241 | NM | MD | Vision Therapy Optometrist |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist | 152W00000X | 2241 | NM | Yes |
| Corneal and Contact Management Optometrist | 152WC0802X | 2241 | NM | |
| Low Vision Rehabilitation Optometrist | 152WL0500X | 2241 | NM | |
| Sports Vision Optometrist | 152WS0006X | 2241 | NM | |
| Vision Therapy Optometrist | 152WV0400X | 2241 | NM | |
| Occupational Vision Optometrist | 152WX0102X | 2241 | NM |
Addresses
Primary practice location
124 W Coal Ave
Gallup, NM 87301-6206
Mailing address
124 W Coal Ave
Gallup, NM 87301-6206
Phone (505) 722-2020
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| NM00O520 | Other | NM | BLUE CROSS BLUE SHIELD NM |
Other providers in Gallup, NM
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 11, 2008. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.