Provider Demographics
NPI:1477532885
Name:BLACKMAN, KEITH WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:WILLIAM
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:PO BOX 19988
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70179-0988
Mailing Address - Country:US
Mailing Address - Phone:504-464-0032
Mailing Address - Fax:504-466-3440
Practice Address - Street 1:11312 JEFFERSON HWY
Practice Address - Street 2:
Practice Address - City:RIVER RIDGE
Practice Address - State:LA
Practice Address - Zip Code:70123-1709
Practice Address - Country:US
Practice Address - Phone:504-464-0032
Practice Address - Fax:504-466-3440
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10367R2083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1679941Medicaid
LAE92097Medicare UPIN
LA4E913Medicare ID - Type UnspecifiedMEDICARE #