Provider Demographics
NPI:1801357090
Name:BLACKWOOD, CAMILLE
Entity type:Individual
Prefix:
First Name:CAMILLE
Middle Name:
Last Name:BLACKWOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 BONITA VISTA RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10552-1301
Mailing Address - Country:US
Mailing Address - Phone:718-644-2885
Mailing Address - Fax:
Practice Address - Street 1:55 BONITA VISTA RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10552-1301
Practice Address - Country:US
Practice Address - Phone:718-644-2885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-29
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW246311245OtherAETNA