Healthcare Provider Details

I. General information

NPI: 1508027632
Provider Name (Legal Business Name): EDMUND LLOYD BLACKLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2008
Last Update Date: 08/30/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 BIGHORN RD
FORT COLLINS CO
80525-3480
US

IV. Provider business mailing address

2025 BIGHORN RD
FORT COLLINS CO
80525-3480
US

V. Phone/Fax

Practice location:
  • Phone: 970-229-9800
  • Fax:
Mailing address:
  • Phone: 970-229-9800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-10856
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number56170
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: