Provider Demographics
NPI:1679521397
Name:BLACKLEDGE, MARK ALLAN (OD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALLAN
Last Name:BLACKLEDGE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5107 N BELT HWY STE Y107
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-1280
Mailing Address - Country:US
Mailing Address - Phone:308-530-6666
Mailing Address - Fax:
Practice Address - Street 1:5107 N BELT HWY STE Y107
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-1280
Practice Address - Country:US
Practice Address - Phone:308-530-6666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE953152W00000X
MO2015007758152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NET90015Medicare UPIN
NE265436BLMedicare ID - Type Unspecified