Provider Demographics
NPI:1033849690
Name:BLACKMON, DAVID GLENN (HAS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:GLENN
Last Name:BLACKMON
Suffix:
Gender:M
Credentials:HAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3813 GULF BLVD APT 312
Mailing Address - Street 2:
Mailing Address - City:ST PETE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33706-3924
Mailing Address - Country:US
Mailing Address - Phone:513-616-8888
Mailing Address - Fax:
Practice Address - Street 1:6218 US HIGHWAY 301 N
Practice Address - Street 2:
Practice Address - City:ELLENTON
Practice Address - State:FL
Practice Address - Zip Code:34222-3065
Practice Address - Country:US
Practice Address - Phone:941-722-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-15
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS5648237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist