Healthcare Provider Details

I. General information

NPI: 1932198181
Provider Name (Legal Business Name): ROBERT GARFIELD BLACKSTOCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11050 MT BELVEDERE BLVD
FORT DRUM NY
13602-2603
US

IV. Provider business mailing address

11050 MT BELVEDERE BLVD
FORT DRUM NY
13602-2603
US

V. Phone/Fax

Practice location:
  • Phone: 315-772-4740
  • Fax:
Mailing address:
  • Phone: 315-772-4740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number217390-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number217390-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: