Provider Demographics
NPI:1710291067
Name:BLAKELY, G WAYMAN (M D)
Entity Type:Individual
Prefix:DR
First Name:G
Middle Name:WAYMAN
Last Name:BLAKELY
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 91357
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90009-1357
Mailing Address - Country:US
Mailing Address - Phone:323-806-8633
Mailing Address - Fax:
Practice Address - Street 1:1911 WILLIAMS DR
Practice Address - Street 2:STE. 200
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-2612
Practice Address - Country:US
Practice Address - Phone:323-806-8633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-28
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA308512084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry