Provider Demographics
NPI:1699356782
Name:BLACKWELL, TIMOTHY (DO)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 WOODSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07860-2313
Mailing Address - Country:US
Mailing Address - Phone:973-300-0222
Mailing Address - Fax:
Practice Address - Street 1:136 WOODSIDE AVE
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:NJ
Practice Address - Zip Code:07860-2313
Practice Address - Country:US
Practice Address - Phone:973-300-0222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-20
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB12227900207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty