NPIMap

Individual provider Active NPI

Michael G Blake, O.D.

  • Optometrist
  • Gallup, NM
National Provider Identifier
1831161264
Registry record updated Dec 11, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
OptometristTaxonomy code 152W00000X
License
2241 Issued in NM
Practice address
124 W Coal Ave
Gallup, NM 87301-6206
Phone
(505) 722-2020
Fax
(505) 863-2204
NPI assigned
Feb 1, 2006
Last updated
Dec 11, 2008By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Dec 11, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 6

Specialty (taxonomy)CodeLicenseStatePrimary
Optometrist 152W00000X 2241 NM Primary
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

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled

State licenses

LicenseStateTypeSpecialty
2241NMMDLow Vision Rehabilitation Optometrist

Organizations & group practices 1

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1138752000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1228953600000",
    "number": "1831161264",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "124 W COAL AVE",
            "city": "GALLUP",
            "state": "NM",
            "postal_code": "873016206",
            "telephone_number": "505-722-2020",
            "fax_number": "505-863-2204"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "124 W COAL AVE",
            "city": "GALLUP",
            "state": "NM",
            "postal_code": "873016206",
            "telephone_number": "505-722-2020",
            "fax_number": "505-863-2204"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BLAKE",
        "first_name": "MICHAEL",
        "middle_name": "G",
        "name_prefix": "Dr.",
        "credential": "O.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-02-01",
        "last_updated": "2008-12-11",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": "NM",
            "license": "2241",
            "primary": true
        },
        {
            "code": "152WC0802X",
            "taxonomy_group": "",
            "desc": "Optometrist, Corneal and Contact Management",
            "state": "NM",
            "license": "2241",
            "primary": false
        },
        {
            "code": "152WL0500X",
            "taxonomy_group": "",
            "desc": "Optometrist, Low Vision Rehabilitation",
            "state": "NM",
            "license": "2241",
            "primary": false
        },
        {
            "code": "152WS0006X",
            "taxonomy_group": "",
            "desc": "Optometrist, Sports Vision",
            "state": "NM",
            "license": "2241",
            "primary": false
        },
        {
            "code": "152WV0400X",
            "taxonomy_group": "",
            "desc": "Optometrist, Vision Therapy",
            "state": "NM",
            "license": "2241",
            "primary": false
        },
        {
            "code": "152WX0102X",
            "taxonomy_group": "",
            "desc": "Optometrist, Occupational Vision",
            "state": "NM",
            "license": "2241",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Gallup, NM

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 11, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.