Provider Demographics
NPI:1912199159
Name:BLACKLOCK, AUDREY DEANNE (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:DEANNE
Last Name:BLACKLOCK
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2790 CLAY EDWARDS DR STE 1240
Mailing Address - Street 2:
Mailing Address - City:N KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64116-3253
Mailing Address - Country:US
Mailing Address - Phone:816-842-2015
Mailing Address - Fax:816-221-3713
Practice Address - Street 1:2790 CLAY EDWARDS DR STE 1240
Practice Address - Street 2:
Practice Address - City:N KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64116-3253
Practice Address - Country:US
Practice Address - Phone:816-842-2015
Practice Address - Fax:816-221-3713
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-34305207W00000X
MO2012008166207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology