Provider Demographics
NPI:1114209541
Name:BOYETT, JOHN BLAKE (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BLAKE
Last Name:BOYETT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:927 FRANKLIN ST SE
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-4306
Mailing Address - Country:US
Mailing Address - Phone:256-539-2728
Mailing Address - Fax:256-539-2666
Practice Address - Street 1:22454 HWY 72 W
Practice Address - Street 2:SUITE 200
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35613
Practice Address - Country:US
Practice Address - Phone:256-233-2332
Practice Address - Fax:256-539-2666
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-12
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO.1657207X00000X
ALDO1657207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL216627Medicaid
AL512-09153OtherBCBS