Provider Demographics
NPI:1215058110
Name:BLACKMON, BILLY JACOB (MD)
Entity type:Individual
Prefix:
First Name:BILLY
Middle Name:JACOB
Last Name:BLACKMON
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 1:154 ROSEMONT ST
Mailing Address - Street 2:
Mailing Address - City:SAINT SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-1777
Mailing Address - Country:US
Mailing Address - Phone:912-580-8162
Mailing Address - Fax:
Practice Address - Street 1:154 ROSEMONT ST
Practice Address - Street 2:
Practice Address - City:SAINT SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-1777
Practice Address - Country:US
Practice Address - Phone:912-580-8162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00589282085R0202X
OH35.0948832085R0202X
GA0011962085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology