Provider Demographics
NPI:1578068102
Name:BLACKWELL, CONNER OWEN (MD)
Entity Type:Individual
Prefix:
First Name:CONNER
Middle Name:OWEN
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1071 DAPPLE CT
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-8772
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 E APPLE ST STE 6258
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2939
Practice Address - Country:US
Practice Address - Phone:937-245-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH35.146641207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program