Individual
DR. MICHAEL G BLAKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
O.D.
Contact information
Practice address
124 W COAL AVE, GALLUP, NM 87301-6206
(505) 722-2020
(505) 863-2204
Mailing address
124 W COAL AVE, GALLUP, NM 87301-6206
(505) 722-2020
(505) 863-2204
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
2241
NM
152WC0802X
Corneal and Contact Management Optometrist
2241
NM
152WL0500X
Low Vision Rehabilitation Optometrist
2241
NM
152WS0006X
Sports Vision Optometrist
2241
NM
152WV0400X
Vision Therapy Optometrist
2241
NM
152WX0102X
Occupational Vision Optometrist
2241
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
NM00O520
BLUE CROSS BLUE SHIELD NM
NM
Enumeration date
02/01/2006
Last updated
12/11/2008
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