Provider Demographics
NPI:1063746972
Name:JONATHAN BLACKER MD
Entity type:Organization
Organization Name:JONATHAN BLACKER MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:BLACKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-795-3443
Mailing Address - Street 1:8000 E. PRENTICE AVENUE
Mailing Address - Street 2:SUITE D-12
Mailing Address - City:GREENWOOD VILLAGE
Mailing Address - State:CO
Mailing Address - Zip Code:80111-2744
Mailing Address - Country:US
Mailing Address - Phone:303-795-3443
Mailing Address - Fax:303-290-6317
Practice Address - Street 1:8000 E. PRENTICE AVENUE
Practice Address - Street 2:SUITE D-12
Practice Address - City:GREENWOOD VILLAGE
Practice Address - State:CO
Practice Address - Zip Code:80111-2744
Practice Address - Country:US
Practice Address - Phone:303-795-3443
Practice Address - Fax:303-290-6317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-24
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO27023207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01270230Medicaid
CO01270230Medicaid