Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | DN011681 | GA |
Y | 1223G0001X | General Practice | DN011681 | GA |
Y | 213EG0000X | General Practice | DN011681 | GA |
NPI | 1003862731 |
---|---|
Provider Name | Dr. John S. Blalock |
First Address | Augusta, GA 30909 |
Second Address | Augusta, GA 30909 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/05/2006 |
Last Update Date | 26/10/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000879095A | (05) | GA |
ZG1681 | (05) | SC |