Provider Demographics
NPI:1083646525
Name:MENDO LAKE UROLOGIC MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:MENDO LAKE UROLOGIC MEDICAL GROUP, INC
Other - Org Name:MENDO LAKE UROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:BLACKWELDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-462-1928
Mailing Address - Street 1:246 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-4533
Mailing Address - Country:US
Mailing Address - Phone:707-462-1928
Mailing Address - Fax:707-462-8642
Practice Address - Street 1:246 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4533
Practice Address - Country:US
Practice Address - Phone:707-462-1928
Practice Address - Fax:707-462-8642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA24853174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ74887ZMedicaid
CAZZZ99729ZMedicare ID - Type UnspecifiedFORT BRAGG PROVIDER #
CAZZZ15652ZMedicare ID - Type UnspecifiedNP PROVIDER #
CAZZZ74887ZMedicare ID - Type UnspecifiedUKIAH PROVIDER #
CAA24161Medicare UPIN
CAZZZ74887ZMedicaid