Provider Demographics
NPI:1396847125
Name:BLACKMER, DAVID A (DPM)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:BLACKMER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3080 E GENTRY WAY
Mailing Address - Street 2:STE 201
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-3013
Mailing Address - Country:US
Mailing Address - Phone:208-319-0497
Mailing Address - Fax:
Practice Address - Street 1:191 ADDISON AVE
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5177
Practice Address - Country:US
Practice Address - Phone:208-733-3881
Practice Address - Fax:208-733-8441
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP118213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1350599Medicare ID - Type UnspecifiedMEDICARE
IDT44261Medicare UPIN