Provider Demographics
NPI:1386687754
Name:BLACKMAN, DONALD M (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:M
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 1:4000 14TH ST
Mailing Address - Street 2:#311
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501
Mailing Address - Country:US
Mailing Address - Phone:951-683-6815
Mailing Address - Fax:951-683-6836
Practice Address - Street 1:4000 14TH ST
Practice Address - Street 2:#311
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501
Practice Address - Country:US
Practice Address - Phone:951-683-6815
Practice Address - Fax:951-683-6836
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG11052207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOG110510Medicare UPIN
CA00G110520Medicare ID - Type Unspecified
A38194Medicare UPIN