Provider Demographics
NPI:1023160561
Name:BLACKMAN, BRUCE ELLIOTT (DO)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ELLIOTT
Last Name:BLACKMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 W COLE RD
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-9430
Mailing Address - Country:US
Mailing Address - Phone:207-283-1118
Mailing Address - Fax:207-286-8792
Practice Address - Street 1:22 W COLE RD
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-9430
Practice Address - Country:US
Practice Address - Phone:207-283-1118
Practice Address - Fax:207-286-8792
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME9242084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME108510000Medicaid
ME012131Medicare ID - Type Unspecified
ME108510000Medicaid