Healthcare Provider Details

I. General information

NPI: 1386771186
Provider Name (Legal Business Name): FRED BLACKWELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 OTIS DR
ALAMEDA CA
94501-5786
US

IV. Provider business mailing address

1600 SHERMAN ST
ALAMEDA CA
94501-2236
US

V. Phone/Fax

Practice location:
  • Phone: 510-748-0940
  • Fax: 510-748-0926
Mailing address:
  • Phone: 510-748-0940
  • Fax: 510-748-0926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberG15873
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: