Provider Demographics
NPI:1104997907
Name:BLAKELEY, PAUL DAVID (CPO FAAOP)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:DAVID
Last Name:BLAKELEY
Suffix:
Gender:M
Credentials:CPO FAAOP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 WILLOW LANE
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29307-1343
Mailing Address - Country:US
Mailing Address - Phone:864-582-4411
Mailing Address - Fax:864-573-6717
Practice Address - Street 1:102 WILLOW LANE
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1343
Practice Address - Country:US
Practice Address - Phone:864-582-4411
Practice Address - Fax:864-573-6717
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Not Answered224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7701424Medicaid
SCDME285Medicaid
NC7701424Medicaid