Provider Demographics
NPI:1093201725
Name:BLACKWELL, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5118 HOMER ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-6622
Mailing Address - Country:US
Mailing Address - Phone:816-517-8806
Mailing Address - Fax:
Practice Address - Street 1:5800 OWNBY DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75205
Practice Address - Country:US
Practice Address - Phone:214-768-5833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-05
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAT8826OtherTDLR
2000038921OtherBOC