Provider Demographics
NPI:1558352971
Name:BLEDSOE, CAREY A (DPM)
Entity Type:Individual
Prefix:MR
First Name:CAREY
Middle Name:A
Last Name:BLEDSOE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 SAN BERNARDINO RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4912
Mailing Address - Country:US
Mailing Address - Phone:909-946-6643
Mailing Address - Fax:909-946-6130
Practice Address - Street 1:901 SAN BERNARDINO RD
Practice Address - Street 2:SUITE 104
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4912
Practice Address - Country:US
Practice Address - Phone:909-946-6643
Practice Address - Fax:909-946-6130
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4008213ES0103X
NM260213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E40080Medicaid
CAU61771Medicare UPIN
CA000E40080Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER