Provider Demographics
NPI:1104903111
Name:BLACKWELL, DAVID MICHAEL II (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:MICHAEL
Last Name:BLACKWELL
Suffix:II
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 N EAST ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-3425
Mailing Address - Country:US
Mailing Address - Phone:317-644-3461
Mailing Address - Fax:317-602-2654
Practice Address - Street 1:907 N EAST ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-3425
Practice Address - Country:US
Practice Address - Phone:317-644-3461
Practice Address - Fax:317-602-2654
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01047203207Q00000X
IN01047203A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1102455200OtherANTHEM PTAN
IN300087633Medicaid
IN224550BMedicare PIN