Provider Demographics
NPI:1154308559
Name:BLACKMAN, RONALD GORDON (MD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:GORDON
Last Name:BLACKMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1073 HUBERT RD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-2520
Mailing Address - Country:US
Mailing Address - Phone:510-832-3795
Mailing Address - Fax:510-268-8081
Practice Address - Street 1:1073 HUBERT RD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-2520
Practice Address - Country:US
Practice Address - Phone:510-832-3795
Practice Address - Fax:510-268-8081
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG4687207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000G46870Medicare ID - Type Unspecified
CAA56574Medicare UPIN