Provider Demographics
NPI:1730163569
Name:BLACKWELL, BARRY (MD)
Entity type:Individual
Prefix:DR
First Name:BARRY
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:741 N GRAND AVE
Mailing Address - Street 2:#210
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-4820
Mailing Address - Country:US
Mailing Address - Phone:262-547-2463
Mailing Address - Fax:262-547-8002
Practice Address - Street 1:741 N GRAND AVE
Practice Address - Street 2:#210
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-4820
Practice Address - Country:US
Practice Address - Phone:262-547-2463
Practice Address - Fax:262-547-8002
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI235560202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30351800Medicaid
WI30351800Medicaid