Healthcare Provider Details

I. General information

NPI: 1578958526
Provider Name (Legal Business Name): KAITLIN R. BLACKARD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2015
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 CHILDRENS LN
NORFOLK VA
23507-1971
US

IV. Provider business mailing address

601 CHILDRENS LN
NORFOLK VA
23507-1971
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-7473
  • Fax: 757-668-7474
Mailing address:
  • Phone: 757-668-7473
  • Fax: 757-668-7474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101264637
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: