Provider Demographics
NPI:1417004359
Name:BLALOCK, TULLY T JR (MD)
Entity Type:Individual
Prefix:
First Name:TULLY
Middle Name:T
Last Name:BLALOCK
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1137
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32902-1137
Mailing Address - Country:US
Mailing Address - Phone:321-952-9696
Mailing Address - Fax:321-952-7937
Practice Address - Street 1:220 BARTON BLVD
Practice Address - Street 2:UNIT C14
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2742
Practice Address - Country:US
Practice Address - Phone:321-639-5177
Practice Address - Fax:321-639-4927
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME26001207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002048700Medicaid
FLD64238Medicare UPIN