Basic Information
| Provider Information | |||||||||
| NPI: | 1619933900 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACKMAN | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 CHURCH ST | ||||||||
| Address2: | DEAN MEDICAL CENTER | ||||||||
| City: | STOUGHTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535891801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088772700 | ||||||||
| FaxNumber: | 6088772726 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 CHURCH ST | ||||||||
| Address2: | DEAN MEDICAL CENTER | ||||||||
| City: | STOUGHTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535891801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088772700 | ||||||||
| FaxNumber: | 6088772726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1400-035 | WI | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.