Individual
KENNETH TODD BLACKNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
275 W LOCUST ST, SHELLEY, ID 83274-1230
(208) 357-3960
Mailing address
618 E 1450 N, SHELLEY, ID 83274-5078
(757) 617-3339
Taxonomy
Speciality
Code
Description
License number
State
208D00000X
General Practice Physician
0101240258
VA
208D00000X
General Practice Physician
Primary
M-11785
ID
Other
Enumeration date
03/28/2007
Last updated
02/03/2016
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