Provider Demographics
NPI:1053405134
Name:BLACKWELL, DEE C (OD)
Entity type:Individual
Prefix:
First Name:DEE
Middle Name:C
Last Name:BLACKWELL
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 1:193 MARS HILL RD
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465-9793
Mailing Address - Country:US
Mailing Address - Phone:601-582-1311
Mailing Address - Fax:601-582-1311
Practice Address - Street 1:193 MARS HILL RD
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465-9793
Practice Address - Country:US
Practice Address - Phone:601-582-1311
Practice Address - Fax:601-582-1311
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS543152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00880091Medicaid
MST20949Medicare UPIN