Provider Demographics
NPI:1366609422
Name:BLACKMAN, JON ARTHUR (MD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:ARTHUR
Last Name:BLACKMAN
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 1:2456 NW SACAGAWEA LN
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-5722
Mailing Address - Country:US
Mailing Address - Phone:503-223-5421
Mailing Address - Fax:
Practice Address - Street 1:2456 NW SACAGAWEA LN
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-5722
Practice Address - Country:US
Practice Address - Phone:503-223-5421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-16
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10870207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORC92227Medicare UPIN