Provider Demographics
NPI:1578592994
Name:BLACKMON, DEMETRIOUS J (MD)
Entity Type:Individual
Prefix:DR
First Name:DEMETRIOUS
Middle Name:J
Last Name:BLACKMON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:250 VILLAGE CENTER PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-9104
Mailing Address - Country:US
Mailing Address - Phone:678-289-0508
Mailing Address - Fax:678-289-0124
Practice Address - Street 1:250 VILLAGE CENTER PWKY
Practice Address - Street 2:SUITE 100
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-9044
Practice Address - Country:US
Practice Address - Phone:678-289-0508
Practice Address - Fax:678-289-0124
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2015-03-04
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Provider Licenses
StateLicense IDTaxonomies
TNMD38696207R00000X
GA57778207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009934159Medicaid
GA662769049AMedicaid
TNP00254515OtherRAILROAD MEDICARE
TN3334458Medicaid
TN4111806OtherBCBS OF TENNESSEE
GA662769049FMedicaid
TN3334459Medicaid
GA581365705OtherCHAMPUS
TN4152444OtherBLUE CROSS
GA581365705OtherCHAMPUS
TN3334459Medicaid
TN4111806OtherBCBS OF TENNESSEE