Provider Demographics
NPI:1164650123
Name:BLANDFORD, JILL MARIE (DO)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:MARIE
Last Name:BLANDFORD
Suffix:
Gender:F
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:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:2095 HENRY TECKLENBURG DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5733
Practice Address - Country:US
Practice Address - Phone:843-402-5035
Practice Address - Fax:843-402-5036
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY03684207R00000X, 2084N0400X
SC12702084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY170948OtherSIHO - NNS
IN201392140Medicaid
KY000001036470OtherANTHEM - NNS
KY50114236OtherPASSPORT - NNS
KY7100321110Medicaid
KY000001036470OtherANTHEM - NNS