Provider Demographics
NPI:1992762439
Name:BLEVINS, WILLIAM LEONARD (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:LEONARD
Last Name:BLEVINS
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:PO BOX 1108
Mailing Address - Street 2:45 CALLE DE CONEJO WILLIAM L BLEVINS MD
Mailing Address - City:EL PRADO
Mailing Address - State:NM
Mailing Address - Zip Code:87529-1108
Mailing Address - Country:US
Mailing Address - Phone:575-776-8669
Mailing Address - Fax:575-776-8669
Practice Address - Street 1:101 OCEAN BLVD
Practice Address - Street 2:MOGUL MEDICAL URGENT CARE
Practice Address - City:TAOS SKI VALLEY
Practice Address - State:NM
Practice Address - Zip Code:87525-0067
Practice Address - Country:US
Practice Address - Phone:575-776-8421
Practice Address - Fax:575-776-8942
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2008-01-10
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2008-01-08
Provider Licenses
StateLicense IDTaxonomies
NM7390207R00000X
MT6464207RX0202X
AK2700207RX0202X
IDM4320207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM341321005Medicare Oscar/Certification
C97369Medicare UPIN