Provider Demographics
NPI:1932465010
Name:BLAKELY, ROBERT ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:ANTHONY
Last Name:BLAKELY
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 1:1 UNIVERSITY OF NEW MEXICO
Mailing Address - Street 2:MSC 10-5530
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131
Mailing Address - Country:US
Mailing Address - Phone:505-272-2269
Mailing Address - Fax:505-272-5821
Practice Address - Street 1:1 UNIVERSITY OF NEW MEXICO
Practice Address - Street 2:MSC 09-5030
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131
Practice Address - Country:US
Practice Address - Phone:505-272-2269
Practice Address - Fax:505-272-5821
Is Sole Proprietor?:No
Enumeration Date:2012-04-03
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2017-10302085R0202X
NMRS2012-04712085N0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program