Provider Demographics
NPI:1659683266
Name:BLACKLEDGE, DOUGLAS HUNT (DO)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:HUNT
Last Name:BLACKLEDGE
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 1:103 BRECKENRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:MS
Mailing Address - Zip Code:39367-3134
Mailing Address - Country:US
Mailing Address - Phone:601-671-1155
Mailing Address - Fax:
Practice Address - Street 1:950 MATTHEW DR
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:MS
Practice Address - Zip Code:39367-2567
Practice Address - Country:US
Practice Address - Phone:601-735-7246
Practice Address - Fax:601-735-7245
Is Sole Proprietor?:No
Enumeration Date:2010-07-12
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-2288207L00000X
MS23160207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03504265Medicaid