Healthcare Provider Details

I. General information

NPI: 1932465010
Provider Name (Legal Business Name): ROBERT ANTHONY BLAKELY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2012
Last Update Date: 03/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 UNIVERSITY OF NEW MEXICO MSC 09-5030
ALBUQUERQUE NM
87131
US

IV. Provider business mailing address

1 UNIVERSITY OF NEW MEXICO MSC 10-5530
ALBUQUERQUE NM
87131
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2269
  • Fax: 505-272-5821
Mailing address:
  • Phone: 505-272-2269
  • Fax: 505-272-5821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD2017-1030
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberRS2012-0471
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: