Provider Demographics
NPI:1700878865
Name:BLACKWELL, ROBERT G (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:G
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:4002 S LOOP 256 STE A
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75801-8492
Mailing Address - Country:US
Mailing Address - Phone:903-731-5442
Mailing Address - Fax:903-723-3325
Practice Address - Street 1:115 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-4781
Practice Address - Country:US
Practice Address - Phone:903-723-8554
Practice Address - Fax:903-723-2054
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2024-11-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXG3159207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX128707001Medicaid
TX128707001Medicaid
TXC13507Medicare UPIN