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KENNETH TODD BLACKNER M.D.

>> General Practice >> Allopathic & Osteopathic Physicians

Registrant NPI Number: 1043339641

Individual Registrant:
 KENNETH TODD BLACKNER M.D.
Gender: M
Sole Proprietor

Location and contact information for practice:
275 W LOCUST ST  SHELLEY, ID 83274-1230 US
Tel: 208-357-3960  Fax: --

Contact information for business:
618 E 1450 N  SHELLEY, ID 83274-5078 US
Tel: 757-617-3339  Fax: --

Registration Information:
NPI: 1043339641
Entity Type: Individual

Specialty information:

PrimaryCodeCategory/DescriptionStateLicense Number
Y208D00000XAllopathic & Osteopathic Physicians
General Practice
IDM-11785
N208D00000XAllopathic & Osteopathic Physicians
General Practice
VA0101240258

Legacy codes, insurance codes and state license numbers:

IssuerNumberStateType




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