Healthcare Provider Details

I. General information

NPI: 1477532885
Provider Name (Legal Business Name): KEITH WILLIAM BLACKMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11312 JEFFERSON HWY
RIVER RIDGE LA
70123-1709
US

IV. Provider business mailing address

PO BOX 19988
NEW ORLEANS LA
70179-0988
US

V. Phone/Fax

Practice location:
  • Phone: 504-464-0032
  • Fax: 504-466-3440
Mailing address:
  • Phone: 504-464-0032
  • Fax: 504-466-3440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number10367R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: