Provider Demographics
NPI:1528021458
Name:BLACKWELL, MICHAEL L (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:425 HOLDERRIETH BLVD STE 208
Mailing Address - Street 2:
Mailing Address - City:TOMBALL
Mailing Address - State:TX
Mailing Address - Zip Code:77375-4552
Mailing Address - Country:US
Mailing Address - Phone:281-357-5515
Mailing Address - Fax:281-255-3440
Practice Address - Street 1:425 HOLDERRIETH BLVD STE 208
Practice Address - Street 2:
Practice Address - City:TOMBALL
Practice Address - State:TX
Practice Address - Zip Code:77375-4552
Practice Address - Country:US
Practice Address - Phone:281-357-5515
Practice Address - Fax:281-255-3440
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3695207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX103453003Medicaid
TXG16426Medicare UPIN
TX103453003Medicaid