Healthcare Provider Details

I. General information

NPI: 1396817409
Provider Name (Legal Business Name): ROBERT CHANDLER BLEDSOE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W COLLEGE ST STE 380
GRAPEVINE TX
76051-3583
US

IV. Provider business mailing address

1600 W COLLEGE ST STE 380
GRAPEVINE TX
76051-3583
US

V. Phone/Fax

Practice location:
  • Phone: 817-481-0868
  • Fax: 817-481-1378
Mailing address:
  • Phone: 817-481-0868
  • Fax: 817-481-1378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG4836
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberG4836
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: