Provider Demographics
NPI:1477528586
Name:BLANTON, MARVIN ASBURY III (MD)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:ASBURY
Last Name:BLANTON
Suffix:III
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 1:1720 REALFOOT AVE
Mailing Address - Street 2:STE 104
Mailing Address - City:UNION CITY
Mailing Address - State:TN
Mailing Address - Zip Code:38261-6004
Mailing Address - Country:US
Mailing Address - Phone:731-885-6662
Mailing Address - Fax:731-885-6643
Practice Address - Street 1:1720 REALFOOT AVE
Practice Address - Street 2:STE 104
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261-6004
Practice Address - Country:US
Practice Address - Phone:731-885-6662
Practice Address - Fax:731-885-6643
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD00005749207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3157432Medicaid
TN3157432Medicaid
B59266Medicare UPIN