Provider Demographics
NPI:1063750891
Name:BLANTON, DEBORAH J (MD)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:J
Last Name:BLANTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 N MILL RIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-5112
Mailing Address - Country:US
Mailing Address - Phone:904-543-1991
Mailing Address - Fax:
Practice Address - Street 1:13947 BEACH BLVD STE 202
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-1200
Practice Address - Country:US
Practice Address - Phone:904-223-1771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-29
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME45016174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator