=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710291067
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | G WAYMAN BLAKELY M. D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2010
-----------------------------------------------------
Last Update Date | 10/15/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1911 WILLIAMS DR STE. 200
-----------------------------------------------------
City | OXNARD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93036-2612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-806-8633
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 91357
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90009-1357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-806-8633
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | A30851
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------