Provider Demographics
NPI:1356487029
Name:BLACKHAM, DANA (MD)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:BLACKHAM
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 1:9776 HOLMAN RD NW
Mailing Address - Street 2:SUITE 108
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98117-2000
Mailing Address - Country:US
Mailing Address - Phone:206-362-9508
Mailing Address - Fax:206-362-1502
Practice Address - Street 1:9776 HOLMAN RD NW
Practice Address - Street 2:SUITE 108
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98117-2000
Practice Address - Country:US
Practice Address - Phone:206-362-9508
Practice Address - Fax:206-362-1502
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2016-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00019644207VX0000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAB398OtherREGENCE BLUE SHIELD
WA1940105Medicaid
WAB398OtherPREMERA BLUE CROSS
WAB398OtherPREMERA BLUE CROSS
WA911237189OtherTAX ID NUMBER
WAB398OtherREGENCE BLUE SHIELD