Provider Demographics
NPI:1619984440
Name:BLACHLEY, JON D (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:D
Last Name:BLACHLEY
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 1:6415 DELOACHE AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75225-2606
Mailing Address - Country:US
Mailing Address - Phone:469-585-5209
Mailing Address - Fax:
Practice Address - Street 1:6415 DELOACHE AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75225-2606
Practice Address - Country:US
Practice Address - Phone:469-585-5209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6238207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01022707OtherRAILROAD
TXTXB107763Medicare PIN