Provider Demographics
NPI:1518920305
Name:BLACKLEY, DONALD WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:WAYNE
Last Name:BLACKLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 36351
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28236-6351
Mailing Address - Country:US
Mailing Address - Phone:704-377-5772
Mailing Address - Fax:704-377-3389
Practice Address - Street 1:2001 VAIL AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1219
Practice Address - Country:US
Practice Address - Phone:704-379-5956
Practice Address - Fax:704-379-6218
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00-38896207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2150703BMedicare PIN
NCE55242Medicare UPIN