Healthcare Provider Details

I. General information

NPI: 1376599217
Provider Name (Legal Business Name): MARK R BLACKWOOD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 02/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 MADBURY RD
DURHAM NH
03824-2021
US

IV. Provider business mailing address

789 CENTRAL AVE
DOVER NH
03820-2526
US

V. Phone/Fax

Practice location:
  • Phone: 603-868-5080
  • Fax: 603-868-7440
Mailing address:
  • Phone: 603-868-5080
  • Fax: 603-868-7440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number8732
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: