Individual
DR. DERRICK LEWIS BLACKWELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
4500 CAMERON VALLEY PKWY STE 100, CHARLOTTE, NC 28211-3542
(704) 384-7910
(704) 384-7914
Mailing address
PO BOX 60447, CHARLOTTE, NC 28260-0447
(704) 384-8640
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
2014-00430
NC
207Q00000X
Family Medicine Physician
5101016178
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
011221
—
SC
Enumeration date
04/25/2007
Last updated
08/01/2022
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