Mendo Lake Urologic Medical Group, Inc

Primary specialty

SpecialistTaxonomy code 174400000X

License

A24853 Issued in CA

Legal business name

MENDO LAKE UROLOGIC MEDICAL GROUP, INC

Doing business as

Mendo Lake Urology

Practice address

246 Hospital Dr
Ukiah, CA 95482-4533

Phone

(707) 462-1928

Fax

(707) 462-8642

NPI assigned

Jul 7, 2006

Last updated

Jul 18, 2007By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Robert Earl Blackwelder, MDNPI 1912992413

Title

Owner

Phone

(707) 462-1928

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Mendo Lake Urology Doing business as

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Robert Earl Blackwelder, M.D.

  • Urology Physician
  • Ukiah, CA
  • NPI 1912992413
  NPD (past) Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1152230400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1184716800000",
    "number": "1083646525",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "246 HOSPITAL DR",
            "city": "UKIAH",
            "state": "CA",
            "postal_code": "954824533",
            "telephone_number": "707-462-1928",
            "fax_number": "707-462-8642"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "246 HOSPITAL DR",
            "city": "UKIAH",
            "state": "CA",
            "postal_code": "954824533",
            "telephone_number": "707-462-1928",
            "fax_number": "707-462-8642"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MENDO LAKE UROLOGIC MEDICAL GROUP, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-07",
        "last_updated": "2007-07-18",
        "status": "A",
        "authorized_official_last_name": "BLACKWELDER",
        "authorized_official_first_name": "ROBERT",
        "authorized_official_middle_name": "EARL",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "707-462-1928",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "",
            "desc": "Specialist",
            "state": "CA",
            "license": "A24853",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "ZZZ74887Z",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Mendo Lake Urology",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Travis Meeks
• Oralia P Mejia
• Robin L Meloche, MHSA COORDINATOR
• Janet G Mendell, LCSW
• Mending Indigenous Spirits
• Mendo Mobile Lab LLC
• Mendocino Care Network (Madrone Care Network)
• Mendocino Community Health Clinic, Inc. (Dora Street Health Center)
• Mendocino Community Health Clinic, Inc.
• Mendocino Community Health Clinic, Inc.

• Specialist in Ukiah, CA
• Providers in Ukiah, CA by specialty
• Specialist in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 18, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.