Provider Demographics
NPI:1518075324
Name:BLACKWOOD, CLARK (OD)
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:
Last Name:BLACKWOOD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-1916
Mailing Address - Country:US
Mailing Address - Phone:303-651-2020
Mailing Address - Fax:303-776-2460
Practice Address - Street 1:2080 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-1916
Practice Address - Country:US
Practice Address - Phone:303-651-2020
Practice Address - Fax:303-776-2460
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO847152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08008476Medicaid
CO08008476Medicaid
CO0422000001Medicare NSC
COT60751Medicare UPIN
COCA0033Medicare PIN