Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207RC0200X | Critical Care Medicine | 311912 | LA |
N | 207RC0200X | Critical Care Medicine | K0266 | TX |
Y | 207RP1001X | Pulmonary Disease | 01081457A | IN |
N | 207RP1001X | Pulmonary Disease | K0266 | TX |
NPI | 1043202849 |
---|---|
Provider Name | Dr. Michael Bendele Blackmon |
First Address | Plano, TX 75093-8122 |
Second Address | Plano, TX 75093-8122 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/08/2005 |
Last Update Date | 13/01/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
311912 | STATE LICENSE (01) | LA |
G44291 | (02) | TX |