Provider Demographics
NPI:1609836824
Name:BLACKMON, GRIFFITH (MD)
Entity Type:Individual
Prefix:DR
First Name:GRIFFITH
Middle Name:
Last Name:BLACKMON
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 1:2520 CHERRY AVE
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-4229
Mailing Address - Country:US
Mailing Address - Phone:360-744-5804
Mailing Address - Fax:206-965-4279
Practice Address - Street 1:2520 CHERRY AVE
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-4229
Practice Address - Country:US
Practice Address - Phone:360-744-5804
Practice Address - Fax:206-965-4279
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00029049207RP1001X, 207LC0200X, 207RS0012X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1014390Medicaid
WA1115468Medicaid
F75056Medicare UPIN
WA1115468Medicaid