Provider Demographics
NPI:1841682374
Name:BLACKWELL, DUSTIN PATRICK (DO)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:PATRICK
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 E SAINT CLAIR ST.
Mailing Address - Street 2:NICHOLE ASH
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-4853
Mailing Address - Country:US
Mailing Address - Phone:812-885-3106
Mailing Address - Fax:812-885-8499
Practice Address - Street 1:700 WILLOW ST STE 203
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1029
Practice Address - Country:US
Practice Address - Phone:812-882-1000
Practice Address - Fax:812-882-1004
Is Sole Proprietor?:No
Enumeration Date:2015-02-20
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02005674B207V00000X
390200000X
IN02005674A207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300028633Medicaid