Provider Demographics
NPI:1114092251
Name:BLACKMON, EDWARD B JR (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:B
Last Name:BLACKMON
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 1:1907 HIGHWAY 97 E
Mailing Address - Street 2:SUITE 220
Mailing Address - City:JOURDANTON
Mailing Address - State:TX
Mailing Address - Zip Code:78026
Mailing Address - Country:US
Mailing Address - Phone:830-769-5916
Mailing Address - Fax:830-769-5917
Practice Address - Street 1:1907 HIGHWAY 97 E STE 220
Practice Address - Street 2:
Practice Address - City:JOURDANTON
Practice Address - State:TX
Practice Address - Zip Code:78026-1538
Practice Address - Country:US
Practice Address - Phone:830-769-5916
Practice Address - Fax:830-769-5917
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0326207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX349733YLLWOtherMEDICARE
TX171496601Medicaid
TX171496601Medicaid
TX349733YLLWOtherMEDICARE