Provider Demographics
NPI:1508027632
Name:BLACKLER, EDMUND LLOYD (MD)
Entity Type:Individual
Prefix:
First Name:EDMUND
Middle Name:LLOYD
Last Name:BLACKLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 BIGHORN RD
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-3480
Mailing Address - Country:US
Mailing Address - Phone:970-229-9800
Mailing Address - Fax:
Practice Address - Street 1:2025 BIGHORN RD
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-3480
Practice Address - Country:US
Practice Address - Phone:970-229-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-10856207Q00000X
CO56170207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808082700Medicaid