Provider Demographics
NPI:1174650071
Name:BLAKE, RICHARD GARY (RDO)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:GARY
Last Name:BLAKE
Suffix:
Gender:M
Credentials:RDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1086 DEEP WOOD DR
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91362-4215
Mailing Address - Country:US
Mailing Address - Phone:805-495-4046
Mailing Address - Fax:808-883-5261
Practice Address - Street 1:21835 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-1838
Practice Address - Country:US
Practice Address - Phone:818-883-9567
Practice Address - Fax:818-883-5261
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD006638156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0198950001Medicare ID - Type Unspecified