Healthcare Provider Details

I. General information

NPI: 1356487029
Provider Name (Legal Business Name): DANA BLACKHAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9776 HOLMAN RD NW SUITE 108
SEATTLE WA
98117-2000
US

IV. Provider business mailing address

9776 HOLMAN RD NW SUITE 108
SEATTLE WA
98117-2000
US

V. Phone/Fax

Practice location:
  • Phone: 206-362-9508
  • Fax: 206-362-1502
Mailing address:
  • Phone: 206-362-9508
  • Fax: 206-362-1502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberMD00019644
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD00019644
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: