Provider Demographics
NPI:1386771186
Name:BLACKWELL, FRED (MD)
Entity type:Individual
Prefix:DR
First Name:FRED
Middle Name:
Last Name:BLACKWELL
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 1:1600 SHERMAN ST
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-2236
Mailing Address - Country:US
Mailing Address - Phone:510-748-0940
Mailing Address - Fax:510-748-0926
Practice Address - Street 1:2100 OTIS DR
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-5786
Practice Address - Country:US
Practice Address - Phone:510-748-0940
Practice Address - Fax:510-748-0926
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG15873207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine