Provider Demographics
NPI:1093748667
Name:BLOEDEL-CLARK, CARLA (MD)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:BLOEDEL-CLARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CARLA
Other - Middle Name:
Other - Last Name:BLOEDEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 27829
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125
Mailing Address - Country:US
Mailing Address - Phone:505-232-1920
Mailing Address - Fax:505-727-9276
Practice Address - Street 1:5150 JOURNAL CENTER BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-5900
Practice Address - Country:US
Practice Address - Phone:505-262-3219
Practice Address - Fax:505-262-3243
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM86180208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM38828Medicaid
NM38828Medicaid