Provider Demographics
NPI:1457305179
Name:BLACKWELDER, JOHN TIMOTHY (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:TIMOTHY
Last Name:BLACKWELDER
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 1:1240 LANCER DR
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-9275
Mailing Address - Country:US
Mailing Address - Phone:509-529-5541
Mailing Address - Fax:
Practice Address - Street 1:1240 LANCER DR
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-9275
Practice Address - Country:US
Practice Address - Phone:509-529-5541
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000206012085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology