Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207SG0201X | Clinical Genetics (M.D.) | 011740 | GA |
NPI | 1154346278 |
---|---|
Provider Name | Ronald D Blackston |
First Address | Decatur, GA 30033-5307 |
Second Address | Decatur, GA 30033-5307 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/07/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D28942 | (02) |