Healthcare Provider Details

I. General information

NPI: 1528590189
Provider Name (Legal Business Name): BRYAN CHRISTOPHER BLACKER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2017
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5409 AVENUE O STE 121
FORT MADISON IA
52627-9673
US

IV. Provider business mailing address

1501 INDIAN SCHOOL RD NE APT D105
ALBUQUERQUE NM
87102-1641
US

V. Phone/Fax

Practice location:
  • Phone: 319-372-5437
  • Fax: 319-376-2719
Mailing address:
  • Phone: 505-377-2773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD-47016
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: