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General NPI Number Information
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NPI Number | 1588933501
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Entity Type | Organization
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Legal Business Name | DR GARY L BLACKMAN OPTOMETRIST, LLC
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Dates
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Enumeration Date | 12/20/2011
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Last Update Date | 10/06/2012
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Provider Practice Location Address
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Address Line | 16 MADERA CT
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City | TAYLORVILLE
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State | IL
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Zip | 62568-8927
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Country | US
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Telephone | 217-553-7709
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Fax |
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Provider Business Mailing Address
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Address Line | 16 MADERA CT
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City | TAYLORVILLE
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State | IL
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Zip | 62568-8927
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Country | US
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Telephone | 217-553-7709
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Fax | 217-303-5424
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Authorized Official
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Title or Position | OWNER
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Name | DR. GARY L BLACKMAN
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Credential | OD
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Telephone | 217-553-7709
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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 |
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License Number State |
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