Basic Information
| Provider Information | |||||||||
| NPI: | 1841682374 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACKWELL | ||||||||
| FirstName: | DUSTIN | ||||||||
| MiddleName: | PATRICK | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1160 E SAINT CLAIR ST. | ||||||||
| Address2: | NICHOLE ASH | ||||||||
| City: | VINCENNES | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475914853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128853106 | ||||||||
| FaxNumber: | 8128858499 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 WILLOW ST STE 203 | ||||||||
| Address2: | |||||||||
| City: | VINCENNES | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475911029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128821000 | ||||||||
| FaxNumber: | 8128821004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2015 | ||||||||
| LastUpdateDate: | 03/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 02005674B | IN | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207VX0000X | 02005674A | IN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics |
ID Information
| ID | Type | State | Issuer | Description | 300028633 | 05 | IN | MEDICAID |