Provider Demographics
NPI:1356330534
Name:BLACKWELL, MARTIN (DO)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 WOODSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07860-2313
Mailing Address - Country:US
Mailing Address - Phone:973-300-0555
Mailing Address - Fax:973-300-0052
Practice Address - Street 1:136 WOODSIDE AVE
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:NJ
Practice Address - Zip Code:07860-2313
Practice Address - Country:US
Practice Address - Phone:973-300-0555
Practice Address - Fax:973-300-0052
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB05321100207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
577565Medicare ID - Type Unspecified
E27347Medicare UPIN