Provider Demographics
NPI:1851503593
Name:BLACKLOCK, DAVID MICHAEL JR (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MICHAEL
Last Name:BLACKLOCK
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:3173 MIRANDA AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMO
Mailing Address - State:CA
Mailing Address - Zip Code:94507-1610
Mailing Address - Country:US
Mailing Address - Phone:415-515-4960
Mailing Address - Fax:
Practice Address - Street 1:350 HAWTHORNE AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3108
Practice Address - Country:US
Practice Address - Phone:510-655-4000
Practice Address - Fax:510-658-8593
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA95723207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1851503593Medicaid
CA00A957230Medicare PIN