=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386687754
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DONALD M BLACKMAN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4000 14TH ST #311
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-683-6815
-----------------------------------------------------
Fax | 951-683-6836
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4000 14TH ST #311
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-683-6815
-----------------------------------------------------
Fax | 951-683-6836
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | G11052
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------