Provider Demographics
NPI:1477697274
Name:BLACKER, JONATHAN EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:EDWARD
Last Name:BLACKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8000 E PRENTICE AVE
Mailing Address - Street 2:SUITE D-12
Mailing Address - City:GREENWOOD VILLAGE
Mailing Address - State:CO
Mailing Address - Zip Code:80111-2744
Mailing Address - Country:US
Mailing Address - Phone:303-795-3443
Mailing Address - Fax:303-290-6317
Practice Address - Street 1:8000 E PRENTICE AVE
Practice Address - Street 2:SUITE D-12
Practice Address - City:GREENWOOD VILLAGE
Practice Address - State:CO
Practice Address - Zip Code:80111-2744
Practice Address - Country:US
Practice Address - Phone:303-795-3443
Practice Address - Fax:303-290-6317
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO27023207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1063746972OtherGROUP NPI
CO01270230Medicaid
CO44176279Medicaid
COF33656Medicare UPIN