Provider Demographics
NPI:1972617413
Name:BLAKELY, PATRICIA (MD)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:BLAKELY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 CAJON ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-5260
Mailing Address - Country:US
Mailing Address - Phone:909-793-7500
Mailing Address - Fax:909-798-2411
Practice Address - Street 1:251 CAJON ST
Practice Address - Street 2:SUITE B
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-5260
Practice Address - Country:US
Practice Address - Phone:909-793-7500
Practice Address - Fax:909-798-2411
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG66318207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G663180Medicaid
E90561Medicare UPIN
CAZZZ31390ZMedicare PIN