Provider Demographics
NPI:1063685352
Name:BLALOCK, JOHN B JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:B
Last Name:BLALOCK
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2660 10TH AVE S
Mailing Address - Street 2:SUITE 238
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-1605
Mailing Address - Country:US
Mailing Address - Phone:205-933-7301
Mailing Address - Fax:
Practice Address - Street 1:541 SUNSET LN STE 103
Practice Address - Street 2:
Practice Address - City:CULPEPER
Practice Address - State:VA
Practice Address - Zip Code:22701-3903
Practice Address - Country:US
Practice Address - Phone:540-829-4440
Practice Address - Fax:540-825-4026
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-08
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL9169208600000X
VA0101263724208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1063685352Medicaid
AL000087171Medicaid
AL000087171Medicaid