Provider Demographics
NPI:1124053392
Name:BLACKLOCK, JERRY (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:BLACKLOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6560 FANNIN ST
Mailing Address - Street 2:SUITE 900
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2761
Mailing Address - Country:US
Mailing Address - Phone:713-441-3800
Mailing Address - Fax:
Practice Address - Street 1:6560 FANNIN ST
Practice Address - Street 2:SUITE 900
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2761
Practice Address - Country:US
Practice Address - Phone:713-441-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG9066207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8GD848OtherBCBS
TXP00216844OtherRAILROAD MEDICARE
TX8EA863OtherBLUE CROSS BLUE SHIELD
TXP01331480OtherRR MEDICARE
TX8R9781OtherBLUE CROSS BLUE SHIELD
TX329394YMQVMedicare PIN
TX8GD848OtherBCBS
TX329394ZSWDMedicare PIN