Provider Demographics
NPI:1689932659
Name:BLANTON, HARRISON DAVIS (MD)
Entity Type:Individual
Prefix:
First Name:HARRISON
Middle Name:DAVIS
Last Name:BLANTON
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 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-302-7100
Mailing Address - Fax:208-302-7155
Practice Address - Street 1:315 E ELM STREET
Practice Address - Street 2:STE 100
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4858
Practice Address - Country:US
Practice Address - Phone:208-302-7100
Practice Address - Fax:208-302-7155
Is Sole Proprietor?:No
Enumeration Date:2012-04-27
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-12857207Q00000X
CODR0053011207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine