Provider Demographics
NPI:1780752253
Name:BLACKMAN, BONNIE (MD)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:BLACKMAN
Suffix:
Gender:F
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 476
Mailing Address - Street 2:
Mailing Address - City:CRESSKILL
Mailing Address - State:NJ
Mailing Address - Zip Code:07626-0476
Mailing Address - Country:US
Mailing Address - Phone:845-406-1347
Mailing Address - Fax:973-506-1954
Practice Address - Street 1:1 FRICK DR
Practice Address - Street 2:
Practice Address - City:DEMAREST
Practice Address - State:NJ
Practice Address - Zip Code:07627-1326
Practice Address - Country:US
Practice Address - Phone:845-406-1347
Practice Address - Fax:973-506-1954
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05869500207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJA64989Medicare UPIN
NJ729606Medicare PIN