Provider Demographics
NPI:1760451595
Name:BLACKMER, LORI L (OD)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:L
Last Name:BLACKMER
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 1:908 SIXTH AVE
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-3802
Mailing Address - Country:US
Mailing Address - Phone:601-798-4182
Mailing Address - Fax:601-798-4770
Practice Address - Street 1:908 SIXTH AVE
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-3802
Practice Address - Country:US
Practice Address - Phone:601-798-4182
Practice Address - Fax:601-798-4770
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS559152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS2230045OtherUNITED HEALTH CARE
MSC02306OtherMEDICARE GROUP
MSDA2690OtherMEDICARE RR GROUP
MS00087010Medicaid
MS1922067016OtherPICAYUNE EYE CLINIC NPI
MS410012249OtherMEDICARE RAILROAD RETIREM
MS410000163Medicare ID - Type Unspecified
MS410012249OtherMEDICARE RAILROAD RETIREM
MST95634Medicare UPIN