Provider Demographics
NPI:1508356866
Name:BLACKSTON. MD, MARILYN (MD)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:BLACKSTON. MD
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 1:3409 WILD CHERRY RD.
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21244
Mailing Address - Country:US
Mailing Address - Phone:443-431-3208
Mailing Address - Fax:
Practice Address - Street 1:3655 OLD COURT RD
Practice Address - Street 2:SUITE 7
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21208
Practice Address - Country:US
Practice Address - Phone:443-431-3208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-12
Last Update Date:2018-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0031470208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice