Healthcare Provider Details

I. General information

NPI: 1144858077
Provider Name (Legal Business Name): OLIVIA CHARLOTTE BLACKSTONE DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11209 N TATUM BLVD STE 255
PHOENIX AZ
85028-6061
US

IV. Provider business mailing address

PO BOX 81064
CLEVELAND OH
44181-0064
US

V. Phone/Fax

Practice location:
  • Phone: 602-494-5050
  • Fax: 866-777-2248
Mailing address:
  • Phone: 602-494-5050
  • Fax: 866-777-2248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number011075
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: