Provider Demographics
NPI:1871550855
Name:BLAKE, PAUL S (DO)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:S
Last Name:BLAKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:PO BOX 37938
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28237-7938
Mailing Address - Country:US
Mailing Address - Phone:704-332-0396
Mailing Address - Fax:704-971-0035
Practice Address - Street 1:3033 EASTWAY DR STE 201
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-6387
Practice Address - Country:US
Practice Address - Phone:704-731-6451
Practice Address - Fax:704-731-6452
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC97-01697207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC276911OtherMAMSI
SCN01697Medicaid
NC891126NMedicaid
NC1126NOtherBCBSNC
NC17696OtherPARTNERS
NC390006903OtherRR MEDICARE
NC561550231MOtherCIGNA
NCG23673Medicare UPIN
SCN01697Medicaid
NC2400448AMedicare PIN