Provider Demographics
NPI:1467129478
Name:BLAYLOCK, JOHN LUTHER
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:LUTHER
Last Name:BLAYLOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2432 W PEORIA AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-4726
Mailing Address - Country:US
Mailing Address - Phone:480-431-5075
Mailing Address - Fax:
Practice Address - Street 1:2432 W PEORIA AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-4726
Practice Address - Country:US
Practice Address - Phone:480-431-5075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-26
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA