Provider Demographics
NPI:1184687352
Name:BLACKMON, JOHN A (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:BLACKMON
Suffix:
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 1:1115 W CALL ST
Mailing Address - Street 2:BIOMEDICAL SCIENCES
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32306-4300
Mailing Address - Country:US
Mailing Address - Phone:850-645-9438
Mailing Address - Fax:850-644-5781
Practice Address - Street 1:2400 MICCOSUKEE RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5314
Practice Address - Country:US
Practice Address - Phone:850-877-2105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 107330207ZP0102X
GA029585207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL61743OtherBCBS
GA00346244AMedicaid
GAC75572Medicare UPIN
FLEA500ZMedicare UPIN