Provider Demographics
NPI:1609071448
Name:BLACKWOOD, KIMATHI SIPHO RICARDO (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMATHI
Middle Name:SIPHO RICARDO
Last Name:BLACKWOOD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:595 HURRICANE SHOALS RD NW STE 100
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-8762
Mailing Address - Country:US
Mailing Address - Phone:404-645-7150
Mailing Address - Fax:770-995-0776
Practice Address - Street 1:890 SECOND STREET
Practice Address - Street 2:SUITE 201
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-6863
Practice Address - Country:US
Practice Address - Phone:478-745-4322
Practice Address - Fax:478-750-8789
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2022-06-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
390200000X
GA063834207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA546478200BBMedicaid
GA546478200CMedicaid