Provider Demographics
NPI:1447209325
Name:BLALOCK, WILLIAM S (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:S
Last Name:BLALOCK
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 1:279 CLEAR SKY CT
Mailing Address - Street 2:SUITE B
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-5653
Mailing Address - Country:US
Mailing Address - Phone:931-906-9869
Mailing Address - Fax:
Practice Address - Street 1:279 CLEAR SKY CT
Practice Address - Street 2:SUITE B
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-5653
Practice Address - Country:US
Practice Address - Phone:931-906-9869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16583208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNA97993Medicare UPIN