Provider Demographics
NPI:1356915037
Name:BLACKWATER, THOMASINA (MD)
Entity type:Individual
Prefix:DR
First Name:THOMASINA
Middle Name:
Last Name:BLACKWATER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 S PALOS VERDES ST APT 632
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-5126
Mailing Address - Country:US
Mailing Address - Phone:520-235-4831
Mailing Address - Fax:
Practice Address - Street 1:1300 N MISSION RD FL 2
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1021
Practice Address - Country:US
Practice Address - Phone:323-409-8255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-17
Last Update Date:2025-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA203016207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine