Provider Demographics
NPI:1518931310
Name:BLACKMAN, STANLEY NEIL (OD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:NEIL
Last Name:BLACKMAN
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 1:2009 ROOSEVELT RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-3765
Mailing Address - Country:US
Mailing Address - Phone:219-462-5501
Mailing Address - Fax:219-462-3238
Practice Address - Street 1:2009 ROOSEVELT RD
Practice Address - Street 2:SUITE D
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-3765
Practice Address - Country:US
Practice Address - Phone:219-462-5501
Practice Address - Fax:219-462-3238
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-16
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001528B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100150190AMedicaid
IN000000084617OtherANTHEM
IN180011OtherUNICARE--BUDD
IN410034633Medicare ID - Type UnspecifiedRAILROAD MEDICARE
IN654180Medicare ID - Type Unspecified
IN180011OtherUNICARE--BUDD
INT69274Medicare UPIN
IN000000084617OtherANTHEM