MEDICARE: DR. AUDREY DEANNE BLACKLOCK MD, PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	04-34305	KS
2	207W00000X	Ophthalmology Physician	2012008166	MO

General Provider Information

NPI Number	:	1912199159
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AUDREY DEANNE BLACKLOCK MD, PHD

Provider Business Mailing Address
First Line	:	2790 CLAY EDWARDS DR STE 1240
Second Line	:
City	:	N KANSAS CITY
State	:	MO
Zip	:	64116-3253
Country	:	US
Telephone Number	:	816-842-2015
Fax Number	:	816-221-3713

Provider Business Practice Location Address
First Line	:	2790 CLAY EDWARDS DR STE 1240
Second Line	:
City	:	N KANSAS CITY
State	:	MO
Zip	:	64116-3253
Country	:	US
Telephone Number	:	816-842-2015
Fax Number	:	816-221-3713

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2007
Last Update Date	:	10/06/2022

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