Individual
DR. DIANE R BLAKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
55 LAKE AVE N, DEPARTMENT OF ADOLESCENT MEDICINE, WORCESTER, MA 01655-0002
(508) 856-5624
Mailing address
PO BOX 62, TURNPIKE STATION, SHREWSBURY, MA 01545-0062
(508) 334-8815
(508) 334-5374
Taxonomy
Speciality
Code
Description
License number
State
2080A0000X
Pediatric Adolescent Medicine Physician
Primary
154470
MA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
3169863
—
MA
Enumeration date
12/05/2005
Last updated
11/10/2020
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