Provider Demographics
NPI:1386058469
Name:DI BLASI, JOHNNY JAMES (DO)
Entity type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:JAMES
Last Name:DI BLASI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 LIBERTY PARK DR
Mailing Address - Street 2:
Mailing Address - City:BRASELTON
Mailing Address - State:GA
Mailing Address - Zip Code:30517-1884
Mailing Address - Country:US
Mailing Address - Phone:904-482-9673
Mailing Address - Fax:
Practice Address - Street 1:127 NORTH ST
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:NY
Practice Address - Zip Code:14020-1631
Practice Address - Country:US
Practice Address - Phone:585-343-6030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA075206207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program