Healthcare Provider Details

I. General information

NPI: 1780752253
Provider Name (Legal Business Name): BONNIE BLACKMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 09/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 FRICK DR
DEMAREST NJ
07627-1326
US

IV. Provider business mailing address

PO BOX 476
CRESSKILL NJ
07626-0476
US

V. Phone/Fax

Practice location:
  • Phone: 845-406-1347
  • Fax: 973-506-1954
Mailing address:
  • Phone: 845-406-1347
  • Fax: 973-506-1954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25MA05869500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: