Provider Demographics
NPI:1992719421
Name:BLACKMON, DONALD L JR (MD)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:L
Last Name:BLACKMON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6160 N DAVIS HWY
Mailing Address - Street 2:SUITE 5
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-6994
Mailing Address - Country:US
Mailing Address - Phone:850-471-2121
Mailing Address - Fax:850-471-2120
Practice Address - Street 1:6160 N DAVIS HWY
Practice Address - Street 2:SUITE 5
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-6994
Practice Address - Country:US
Practice Address - Phone:850-471-2121
Practice Address - Fax:850-471-2120
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME48954207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL17667OtherBCBS
FL037239200Medicaid
FL037239200Medicaid
C82832Medicare UPIN