Provider Demographics
NPI:1447557657
Name:BLALOCK, ANDREW LEE (IDC)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:LEE
Last Name:BLALOCK
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 WEST MAIN ST
Mailing Address - Street 2:APT 47
Mailing Address - City:NIANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06357-1731
Mailing Address - Country:US
Mailing Address - Phone:305-492-5489
Mailing Address - Fax:
Practice Address - Street 1:97 W MAIN ST
Practice Address - Street 2:APT 47
Practice Address - City:NIANTIC
Practice Address - State:CT
Practice Address - Zip Code:06357-1749
Practice Address - Country:US
Practice Address - Phone:305-492-5489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-24
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman