Provider Demographics
NPI:1235195827
Name:BLAKEMORE, WILLIAM S (MD)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:S
Last Name:BLAKEMORE
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:PO BOX 1077
Mailing Address - Street 2:101 MARK DR
Mailing Address - City:EDENTON
Mailing Address - State:NC
Mailing Address - Zip Code:27932-1077
Mailing Address - Country:US
Mailing Address - Phone:252-482-7471
Mailing Address - Fax:252-482-5465
Practice Address - Street 1:101 MARK DR
Practice Address - Street 2:
Practice Address - City:EDENTON
Practice Address - State:NC
Practice Address - Zip Code:27932-1704
Practice Address - Country:US
Practice Address - Phone:252-482-7471
Practice Address - Fax:252-482-5465
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC24730152WC0802X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC180002116OtherRAILROAD MEDICARE
16180OtherBC
NC8916180Medicaid
NC204842Medicare PIN
D62770Medicare UPIN
NC8916180Medicaid