Provider Demographics
NPI:1518917517
Name:BLANKENSHIP, DANIEL R (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:R
Last Name:BLANKENSHIP
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:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-0370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:706-494-3008
Practice Address - Street 1:2300 MANCHESTER EXPY
Practice Address - Street 2:STE C003
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-6802
Practice Address - Country:US
Practice Address - Phone:706-324-7753
Practice Address - Fax:706-324-7756
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052686207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL114083Medicaid
GA511I040035OtherMEDICARE PTAN
GA710405327Medicaid
I30629Medicare UPIN
P00243310Medicare ID - Type UnspecifiedRAILROAD MEDICARE
GA710405327AMedicaid