Healthcare Provider Details

I. General information

NPI: 1689646473
Provider Name (Legal Business Name): CARL ERNST BLUNCK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W OTTLEY AVE
FRUITA CO
81521-2118
US

IV. Provider business mailing address

2055 NORMANDIE DR 108
MONTGOMERY AL
36111-2732
US

V. Phone/Fax

Practice location:
  • Phone: 970-858-2186
  • Fax: 970-858-2208
Mailing address:
  • Phone: 334-288-4624
  • Fax: 334-280-3628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME55224
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number00012036
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: