Provider Demographics
NPI:1447349691
Name:BLACKMAN, DOUGLAS A (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:A
Last Name:BLACKMAN
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 1:1002 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1439
Mailing Address - Country:US
Mailing Address - Phone:336-387-8100
Mailing Address - Fax:336-387-8202
Practice Address - Street 1:1002 N CHURCH ST
Practice Address - Street 2:STE 302
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1449
Practice Address - Country:US
Practice Address - Phone:336-387-8100
Practice Address - Fax:336-387-8202
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC99-00427208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC185173OtherMEDCOST
NC126PNOtherBLUE CROSS BLUE SHIELD OF
NC89126PNMedicaid
NC126PNOtherBLUE CROSS BLUE SHIELD OF
H11463Medicare UPIN