Provider Demographics
NPI:1043202849
Name:BLACKMON, MICHAEL BENDELE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BENDELE
Last Name:BLACKMON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:6124 W PARKER RD
Mailing Address - Street 2:SUITE 530
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-8122
Mailing Address - Country:US
Mailing Address - Phone:214-778-1075
Mailing Address - Fax:214-778-1237
Practice Address - Street 1:6124 W PARKER RD
Practice Address - Street 2:SUITE 530
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-8122
Practice Address - Country:US
Practice Address - Phone:214-778-1075
Practice Address - Fax:214-778-1237
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA311912207RC0200X
TXK0266207RC0200X, 207RP1001X
IN01081457A207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA311912OtherSTATE LICENSE