Provider Demographics
NPI:1235361197
Name:BLACKER, ADAM BRYCE (OD, MS)
Entity Type:Individual
Prefix:DR
First Name:ADAM
Middle Name:BRYCE
Last Name:BLACKER
Suffix:
Gender:M
Credentials:OD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5865 W UTOPIA RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-5251
Mailing Address - Country:US
Mailing Address - Phone:623-572-3919
Mailing Address - Fax:
Practice Address - Street 1:5865 W UTOPIA RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-5251
Practice Address - Country:US
Practice Address - Phone:623-572-3919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-11
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1710152W00000X
IDODP-100258152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist