Provider Demographics
NPI:1447237623
Name:BLAIR, MOTT PARKS IV (MD)
Entity Type:Individual
Prefix:DR
First Name:MOTT
Middle Name:PARKS
Last Name:BLAIR
Suffix:IV
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 1:404 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WALLACE
Mailing Address - State:NC
Mailing Address - Zip Code:28466-2726
Mailing Address - Country:US
Mailing Address - Phone:910-285-2134
Mailing Address - Fax:910-285-3380
Practice Address - Street 1:125 RIVER VINE PKWY
Practice Address - Street 2:
Practice Address - City:WALLACE
Practice Address - State:NC
Practice Address - Zip Code:28466-2377
Practice Address - Country:US
Practice Address - Phone:910-285-2134
Practice Address - Fax:910-285-3380
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC38496207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC16113OtherBLUE CROSS BLUE SHEILD
NC561711105OtherTAX ID
NC8916113Medicaid
NC16113OtherBLUE CROSS BLUE SHEILD
NC8916113Medicaid