Provider Demographics
NPI:1750370862
Name:BLACKWELL, BRUCE (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:BLACKWELL
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:PO BOX 522468
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32752-2468
Mailing Address - Country:US
Mailing Address - Phone:407-389-5300
Mailing Address - Fax:407-389-5363
Practice Address - Street 1:4137 HUNTERS PARK LN
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-7669
Practice Address - Country:US
Practice Address - Phone:407-304-1710
Practice Address - Fax:407-304-1778
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME57535207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C82835Medicare UPIN