Provider Demographics
NPI:1316930571
Name:WYNDAL K BLANKENSHIP MD PA
Entity type:Organization
Organization Name:WYNDAL K BLANKENSHIP MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-678-6621
Mailing Address - Street 1:120 S JOHN SIMS PKWY
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:FL
Mailing Address - Zip Code:32580-1212
Mailing Address - Country:US
Mailing Address - Phone:850-678-6621
Mailing Address - Fax:850-729-0331
Practice Address - Street 1:120 S JOHN SIMS PKWY
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:FL
Practice Address - Zip Code:32580-1212
Practice Address - Country:US
Practice Address - Phone:850-678-6621
Practice Address - Fax:850-729-0331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL256934500Medicaid
46862OtherBC NUMBER
FLN1099OtherEDI SENDER NUMBER
FLG90327Medicare UPIN
FL256934500Medicaid