Basic Information
| Provider Information | |||||||||
| NPI: | 1245220110 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACKWELL | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | ERIC | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3601 4TH ST # MS 8340 | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794305865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067610770 | ||||||||
| FaxNumber: | 8067610776 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 4TH ST | ||||||||
| Address2: | SUITE 3B100 | ||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794308340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067432340 | ||||||||
| FaxNumber: | 8067431775 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 03/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085U0001X | E6996 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound |
ID Information
| ID | Type | State | Issuer | Description | 134414506 | 05 | TX | MEDICAID | 44304 | 05 | NM | MEDICAID | A052 | 01 | NM | TRIWEST | OTHER | X5317 | 05 | NM | MEDICAID | 108700100 | 01 | TX | FRISTCARE COMMERCIAL | OTHER | 134414501 | 05 | TX | MEDICAID | 80807Z | 01 | TX | HMO BLUE | OTHER | 108700101 | 05 | TX | MEDICAID | 44304 | 01 | NM | PRESBYTERIAN COMMERCIAL | OTHER | 80R001 | 01 | TX | BC/BS | OTHER | 100034690A | 05 | OK | MEDICAID |