Healthcare Provider Details

I. General information

NPI: 1174785364
Provider Name (Legal Business Name): LISA CHRISTINE BLACKLOCK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2008
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DEPARTMENT OF RADIOLOGY 1 UNIVERSITY OF NEW MEXICO MSC10 5530
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2269
  • Fax:
Mailing address:
  • Phone: 505-272-1476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMZ2011-0401
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License NumberMZ2011-0401
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: