Provider Demographics
NPI:1205914884
Name:BLACKMAN, SPENCER L (MD)
Entity type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:L
Last Name:BLACKMAN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 EMBARCADERO CTR STE 1900
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94111-3723
Mailing Address - Country:US
Mailing Address - Phone:415-658-6791
Mailing Address - Fax:802-847-7559
Practice Address - Street 1:53 STATE ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02109-2820
Practice Address - Country:US
Practice Address - Phone:617-903-5000
Practice Address - Fax:415-252-7176
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA84995207Q00000X
NC2020-04415207Q00000X
TXV4643207Q00000X
CAA88542207Q00000X
VT042.0013274207Q00000X
MA254843207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
00A885420Medicare ID - Type Unspecified