Provider Demographics
NPI:1619052016
Name:BLACKWOOD, ERIC DEAN (DC)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:DEAN
Last Name:BLACKWOOD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-2759
Mailing Address - Country:US
Mailing Address - Phone:918-683-2258
Mailing Address - Fax:918-683-2258
Practice Address - Street 1:2025 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-2759
Practice Address - Country:US
Practice Address - Phone:918-683-2258
Practice Address - Fax:918-683-2258
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3585111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKU92217Medicare UPIN