Provider Demographics
NPI:1619170529
Name:BLANKS, DEIDRA (MD)
Entity Type:Individual
Prefix:
First Name:DEIDRA
Middle Name:
Last Name:BLANKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1839 QUIET CV
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3857
Mailing Address - Country:US
Mailing Address - Phone:910-323-1463
Mailing Address - Fax:910-323-1575
Practice Address - Street 1:1839 QUIET CV
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3857
Practice Address - Country:US
Practice Address - Phone:910-323-1463
Practice Address - Fax:910-323-1575
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006-00621207YX0905X, 207YX0901X
MO2011003947207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
No207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1619170529Medicaid