Provider Demographics
NPI:1336828680
Name:BLACKMAN, MARY CHRISSEN LOY (OD)
Entity type:Individual
Prefix:DR
First Name:MARY CHRISSEN LOY
Middle Name:
Last Name:BLACKMAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15074 GOETHALS AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-1144
Mailing Address - Country:US
Mailing Address - Phone:917-691-8678
Mailing Address - Fax:
Practice Address - Street 1:150 BROADWAY RM 1401
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-4378
Practice Address - Country:US
Practice Address - Phone:212-233-2344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009801152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist