Provider Demographics
NPI:1033186945
Name:BLACKWOOD, DWIGHT E (OD)
Entity Type:Individual
Prefix:
First Name:DWIGHT
Middle Name:E
Last Name:BLACKWOOD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1851 N WEBB RD
Mailing Address - Street 2:ATTN FLR2
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-3413
Mailing Address - Country:US
Mailing Address - Phone:316-636-2010
Mailing Address - Fax:316-858-3830
Practice Address - Street 1:611 MAIN ST
Practice Address - Street 2:
Practice Address - City:NEODESHA
Practice Address - State:KS
Practice Address - Zip Code:66757-1632
Practice Address - Country:US
Practice Address - Phone:620-325-2020
Practice Address - Fax:620-325-2056
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS09251152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100089680BMedicaid
KS410036020OtherRAILROAD MEDICARE
KSCD2825OtherRAIL ROAD MEDICARE GROUP
KSCD2825OtherRAIL ROAD MEDICARE GROUP
KS052573Medicare PIN