Provider Demographics
NPI:1710079819
Name:BLACKWELL, DARRELL KEVIN (DO)
Entity Type:Individual
Prefix:
First Name:DARRELL
Middle Name:KEVIN
Last Name:BLACKWELL
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 1:1490 PARK AVE NW
Mailing Address - Street 2:SUITE 5
Mailing Address - City:NORTON
Mailing Address - State:VA
Mailing Address - Zip Code:24273-1631
Mailing Address - Country:US
Mailing Address - Phone:276-439-1440
Mailing Address - Fax:276-439-1441
Practice Address - Street 1:1490 PARK AVE NW
Practice Address - Street 2:SUITE 5
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-1631
Practice Address - Country:US
Practice Address - Phone:276-439-1440
Practice Address - Fax:276-439-1441
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102050073207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1710079819Medicaid
VAVV6258AMedicare PIN
VA00X674N05Medicare PIN