Provider Demographics
NPI:1457476038
Name:BLACKWATER, NORMA LYNN (MD)
Entity Type:Individual
Prefix:
First Name:NORMA
Middle Name:LYNN
Last Name:BLACKWATER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 W 6TH ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-1833
Mailing Address - Country:US
Mailing Address - Phone:213-202-3970
Mailing Address - Fax:213-975-9257
Practice Address - Street 1:1125 W 6TH ST
Practice Address - Street 2:SUITE 103
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1833
Practice Address - Country:US
Practice Address - Phone:213-202-3970
Practice Address - Fax:213-975-9257
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG83912208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G839120Medicaid