Provider Demographics
NPI:1194752576
Name:BLACKMAN, LAUREL EVE (DO, MBA)
Entity type:Individual
Prefix:DR
First Name:LAUREL
Middle Name:EVE
Last Name:BLACKMAN
Suffix:
Gender:F
Credentials:DO, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3312 GLENVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78703-1447
Mailing Address - Country:US
Mailing Address - Phone:512-228-2441
Mailing Address - Fax:
Practice Address - Street 1:6 GLEN COVE DR
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:ME
Practice Address - Zip Code:04856-4272
Practice Address - Country:US
Practice Address - Phone:512-228-2441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP100232952084P0800X
MEDO25152084P0800X
CT054073390200000X
TXM47152084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8K8420Medicare PIN