Provider Demographics
NPI:1154346278
Name:BLACKSTON, RONALD D (MD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:D
Last Name:BLACKSTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2165 N DECATUR RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-5307
Mailing Address - Country:US
Mailing Address - Phone:404-778-8553
Mailing Address - Fax:
Practice Address - Street 1:2165 N DECATUR RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5307
Practice Address - Country:US
Practice Address - Phone:404-778-8553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011740207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA3755DQZMedicare ID - Type Unspecified
D28942Medicare UPIN