Provider Demographics
NPI:1366483638
Name:BLACKWELL, KENDALL LEON (DPM)
Entity Type:Individual
Prefix:DR
First Name:KENDALL
Middle Name:LEON
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 GLENDALE DR SW
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-4678
Mailing Address - Country:US
Mailing Address - Phone:252-237-0138
Mailing Address - Fax:
Practice Address - Street 1:1704 GLENDALE DR SW
Practice Address - Street 2:SUITE A
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-4678
Practice Address - Country:US
Practice Address - Phone:252-237-0138
Practice Address - Fax:252-237-7903
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC238213ES0103X, 213ES0131X, 213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC79-0804GMedicaid
NC79-0804GMedicaid
NCT83248Medicare UPIN