Basic Information
| Provider Information | |||||||||
| NPI: | 1518920305 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACKLEY | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 36351 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282366351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043775772 | ||||||||
| FaxNumber: | 7043773389 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 VAIL AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282071219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043795956 | ||||||||
| FaxNumber: | 7043796218 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 08/21/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 00-38896 | NC | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.