Provider Demographics
NPI:1881696433
Name:BLACKSTOCK, TERRI (MD)
Entity type:Individual
Prefix:
First Name:TERRI
Middle Name:
Last Name:BLACKSTOCK
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 1:124 SAWTOOTH OAK ST
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71901-7160
Mailing Address - Country:US
Mailing Address - Phone:501-623-7800
Mailing Address - Fax:501-623-7866
Practice Address - Street 1:124 SAWTOOTH OAK ST
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901-7160
Practice Address - Country:US
Practice Address - Phone:501-623-7800
Practice Address - Fax:501-623-7866
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN8309207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5K269OtherBCBS
AR146525002Medicaid
AR146525002Medicaid