Basic Information
Provider Information | |||||||||
NPI: | 1619933900 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLACKMAN | ||||||||
FirstName: | JON | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | OD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1400-035 | WI | Y |   | Eye and Vision Services Providers | Optometrist |   |
No ID Information.