Provider Demographics
NPI:1568811842
Name:BLANDFORD, JONATHAN (DO)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:BLANDFORD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3346 PROFESSIONAL PARK
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-4551
Mailing Address - Country:US
Mailing Address - Phone:270-852-8934
Mailing Address - Fax:270-852-8924
Practice Address - Street 1:3346 PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-4551
Practice Address - Country:US
Practice Address - Phone:270-852-8934
Practice Address - Fax:270-852-8924
Is Sole Proprietor?:No
Enumeration Date:2016-06-08
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC218763390200000X
KY04539207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300029986Medicaid
KY7100604950Medicaid