Basic Information
| Provider Information | |||||||||
| NPI: | 1932465010 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAKELY | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | ANTHONY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 UNIVERSITY OF NEW MEXICO | ||||||||
| Address2: | MSC 10-5530 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052722269 | ||||||||
| FaxNumber: | 5052725821 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 UNIVERSITY OF NEW MEXICO | ||||||||
| Address2: | MSC 09-5030 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052722269 | ||||||||
| FaxNumber: | 5052725821 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2012 | ||||||||
| LastUpdateDate: | 03/21/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD2017-1030 | NM | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085N0700X | RS2012-0471 | NM | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.