Provider Demographics
NPI:1548638141
Name:W. CYNTHIA BLAYLOCK, OD, INC
Entity type:Organization
Organization Name:W. CYNTHIA BLAYLOCK, OD, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WEISHING
Authorized Official - Middle Name:CYNTHIA
Authorized Official - Last Name:BLAYLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:317-985-6420
Mailing Address - Street 1:1955 MONUMENT BLVD
Mailing Address - Street 2:SUITE 4-A
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-3873
Mailing Address - Country:US
Mailing Address - Phone:925-326-0120
Mailing Address - Fax:925-326-3120
Practice Address - Street 1:1955 MONUMENT BLVD
Practice Address - Street 2:SUITE 4-A
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-3873
Practice Address - Country:US
Practice Address - Phone:925-326-0120
Practice Address - Fax:925-326-3120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-14
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 14513 TPG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty