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General NPI Number Information
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NPI Number | 1336828680
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Entity Type | Individual
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Provider Name | MARY CHRISSEN LOY BLACKMAN OD
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Gender | Female
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Dates
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Enumeration Date | 07/13/2023
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Last Update Date | 07/13/2023
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Provider Practice Location Address
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Address Line | 150 BROADWAY RM 1401
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City | NEW YORK
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State | NY
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Zip | 10038-4378
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Country | US
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Telephone | 212-233-2344
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Fax |
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Provider Business Mailing Address
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Address Line | 15074 GOETHALS AVE APT 2
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City | JAMAICA
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State | NY
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Zip | 11432-1144
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Country | US
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Telephone | 917-691-8678
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 009801
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License Number State | NY
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