Provider Demographics
NPI:1427119502
Name:BLAKELY, CHARLES ADAMS (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ADAMS
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 1:3437 CALLE SUENOS SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-6712
Mailing Address - Country:US
Mailing Address - Phone:505-896-4093
Mailing Address - Fax:
Practice Address - Street 1:FORT DEFIANCE INDIAN HOSPITAL
Practice Address - Street 2:CORNER ROUTE N7 AND N12
Practice Address - City:FORT DEFIANCE
Practice Address - State:AZ
Practice Address - Zip Code:86504
Practice Address - Country:US
Practice Address - Phone:928-729-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO22395207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000R4843OtherNM MED
AZ638679OtherAHCCCS
AZ638679OtherAHCCCS