Provider Demographics
NPI:1376711945
Name:BLACKWELL, JAMES L (DO)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:L
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 GREAT TEAYS BLVD STE 6
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-9552
Mailing Address - Country:US
Mailing Address - Phone:304-757-6999
Mailing Address - Fax:304-757-3252
Practice Address - Street 1:3016 GREAT TEAYS BLVD
Practice Address - Street 2:
Practice Address - City:SCOTT DEPOT
Practice Address - State:WV
Practice Address - Zip Code:25560-9552
Practice Address - Country:US
Practice Address - Phone:304-757-6999
Practice Address - Fax:304-757-3252
Is Sole Proprietor?:No
Enumeration Date:2008-02-15
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1090207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0041093000Medicaid
F12380Medicare UPIN
WV0041093000Medicaid
2030653Medicare PIN
2030657Medicare PIN
2030651Medicare PIN
2030654Medicare PIN
WVBL0766667Medicare PIN
2030652Medicare PIN
2030655Medicare PIN
WVBL0766666Medicare PIN