Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207XS0117X | Orthopaedic Spine Surgeon | G4687 | CA |
NPI | 1154308559 |
---|---|
Provider Name | Dr. Ronald Gordon Blackman |
First Address | Oakland, CA 94610-2520 |
Second Address | Oakland, CA 94610-2520 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/12/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
A56574 | (02) | CA |