Provider Demographics
NPI:1528590189
Name:BLACKER, BRYAN CHRISTOPHER (MD)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:CHRISTOPHER
Last Name:BLACKER
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 1:1501 INDIAN SCHOOL RD NE APT D105
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-1641
Mailing Address - Country:US
Mailing Address - Phone:505-377-2773
Mailing Address - Fax:
Practice Address - Street 1:5409 AVENUE O STE 121
Practice Address - Street 2:
Practice Address - City:FORT MADISON
Practice Address - State:IA
Practice Address - Zip Code:52627-9673
Practice Address - Country:US
Practice Address - Phone:319-372-5437
Practice Address - Fax:319-376-2719
Is Sole Proprietor?:No
Enumeration Date:2017-03-31
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-47016208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics