Provider Demographics
NPI:1396798013
Name:BLOCKER, DONALD W (OD)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:W
Last Name:BLOCKER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 S BROADWAY
Mailing Address - Street 2:P O BOX 470
Mailing Address - City:PORTLAND
Mailing Address - State:TN
Mailing Address - Zip Code:37148-1619
Mailing Address - Country:US
Mailing Address - Phone:615-325-2020
Mailing Address - Fax:615-325-5862
Practice Address - Street 1:605 S BROADWAY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TN
Practice Address - Zip Code:37148-1619
Practice Address - Country:US
Practice Address - Phone:615-325-2020
Practice Address - Fax:615-325-5862
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD0454152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3595433Medicaid
TNU25065Medicare UPIN
TN0728430001Medicare NSC
TN3595433Medicare PIN