Provider Demographics
NPI:1154423648
Name:BLACKWOOD, ROBERT SEAN (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:SEAN
Last Name:BLACKWOOD
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:PO BOX 15645
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-877-8661
Mailing Address - Fax:702-877-5140
Practice Address - Street 1:2450 W CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2179
Practice Address - Country:US
Practice Address - Phone:702-877-8661
Practice Address - Fax:702-877-5140
Is Sole Proprietor?:No
Enumeration Date:2006-09-04
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME72790207L00000X
NV15001207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1154423648Medicaid
UT1154423648Medicaid
FL252634400Medicaid
NVV107009Medicare PIN
FL41933XMedicare PIN
NV1154423648Medicaid
FL41933ZMedicare PIN
FL252634400Medicaid