Provider Demographics
NPI:1578601357
Name:BLACKMAN, JANINE A (MD)
Entity Type:Individual
Prefix:DR
First Name:JANINE
Middle Name:A
Last Name:BLACKMAN
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 1:2811 WILSHIRE BOULEVARD, STE 610
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-4814
Mailing Address - Country:US
Mailing Address - Phone:310-453-2335
Mailing Address - Fax:214-393-4645
Practice Address - Street 1:2811 WILSHIRE BOULEVARD, STE 610
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-4814
Practice Address - Country:US
Practice Address - Phone:310-453-2335
Practice Address - Fax:214-393-4645
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD57494207Q00000X
CAG158880207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDH52661Medicare UPIN