Provider Demographics
NPI:1245218726
Name:BLANTON, KEVIN J (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:J
Last Name:BLANTON
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 801143
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-1143
Mailing Address - Country:US
Mailing Address - Phone:573-331-5583
Mailing Address - Fax:573-331-5079
Practice Address - Street 1:1012 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-5044
Practice Address - Country:US
Practice Address - Phone:573-431-0330
Practice Address - Fax:573-471-0461
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD103563208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO43074141063801A097OtherTRICARE NUMBER
MO338231OtherHEALTHLINK NUMBER
MO208843300Medicaid
MO430741410OtherFIRST HEALTH NUMBER
MO111887OtherBCBS MO NUMBER