Provider Demographics
NPI:1861406092
Name:BLACKFORD, MINDY M (OD)
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:M
Last Name:BLACKFORD
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 1:404 S ELSON ST
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-3449
Mailing Address - Country:US
Mailing Address - Phone:660-665-3564
Mailing Address - Fax:660-665-2202
Practice Address - Street 1:404 S ELSON ST
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-3449
Practice Address - Country:US
Practice Address - Phone:660-665-3564
Practice Address - Fax:660-665-2202
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006018231152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO317585305Medicaid
MO259781397Medicare PIN
MO317585305Medicaid
MO1191710003Medicare NSC