Provider Demographics
NPI:1326041195
Name:BLACKWELL, CRAIG (MD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1667 DOMINICAN WAY
Mailing Address - Street 2:STE 130
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95065-1529
Mailing Address - Country:US
Mailing Address - Phone:831-462-9225
Mailing Address - Fax:831-462-6285
Practice Address - Street 1:1667 DOMINICAN WAY
Practice Address - Street 2:STE 130
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1529
Practice Address - Country:US
Practice Address - Phone:831-462-9225
Practice Address - Fax:831-462-6285
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG52516207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G525160Medicaid
CA0755390001Medicare NSC
A52281Medicare UPIN
CA00G525160Medicaid