Provider Demographics
NPI:1912992413
Name:BLACKWELDER, ROBERT EARL (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EARL
Last Name:BLACKWELDER
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:PO BOX 2739
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-2739
Mailing Address - Country:US
Mailing Address - Phone:707-463-8000
Mailing Address - Fax:707-462-1111
Practice Address - Street 1:260 HOSPITAL DR STE 201
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4533
Practice Address - Country:US
Practice Address - Phone:707-463-8000
Practice Address - Fax:707-462-1111
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAB7832454208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ74887ZMedicaid
CALAB11989FMedicaid
CA340004324Medicare ID - Type UnspecifiedRAILROAD MEDICARE #
CAZZZ99532ZMedicare ID - Type UnspecifiedLAKEPORT PROVIDER #
CAZZZ74887ZMedicare ID - Type UnspecifiedUKIAH PROVIDER #
CAZZZ74887ZMedicaid
CALAB11989FMedicaid