Provider Demographics
NPI:1134312531
Name:STANLEY N. BLACKMAN, O.D., P.C.
Entity Type:Organization
Organization Name:STANLEY N. BLACKMAN, O.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:N
Authorized Official - Last Name:BLACKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:219-462-5501
Mailing Address - Street 1:2009 ROOSEVELT RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-3765
Mailing Address - Country:US
Mailing Address - Phone:219-462-5501
Mailing Address - Fax:219-462-3238
Practice Address - Street 1:2009 ROOSEVELT RD
Practice Address - Street 2:SUITE D
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-3765
Practice Address - Country:US
Practice Address - Phone:219-462-5501
Practice Address - Fax:219-462-3238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001528B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1518931310OtherNPI INDIVIDUAL
IN000000084617OtherANTHEM
IN000000084617OtherANTHEM
IN654180Medicare PIN