Provider Demographics
NPI:1700874286
Name:BLACKHART, BRUCE ALAN (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:ALAN
Last Name:BLACKHART
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 W H ST
Mailing Address - Street 2:STE 200
Mailing Address - City:OAKDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95361-3588
Mailing Address - Country:US
Mailing Address - Phone:209-848-1005
Mailing Address - Fax:209-845-8918
Practice Address - Street 1:1425 W H ST
Practice Address - Street 2:STE 200
Practice Address - City:OAKDALE
Practice Address - State:CA
Practice Address - Zip Code:95361-3588
Practice Address - Country:US
Practice Address - Phone:209-848-1005
Practice Address - Fax:209-845-8918
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-10
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG65918207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G659180Medicaid
CA00G659180Medicare PIN
CAF13911Medicare UPIN