Provider Demographics
NPI:1770677635
Name:BLACKWELL, SAMUEL DWIGHT (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:DWIGHT
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1011 PEMBERTON HILL RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-4266
Mailing Address - Country:US
Mailing Address - Phone:919-367-9355
Mailing Address - Fax:919-367-9276
Practice Address - Street 1:1011 PEMBERTON HILL RD
Practice Address - Street 2:SUITE 101
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-4266
Practice Address - Country:US
Practice Address - Phone:919-367-9355
Practice Address - Fax:919-367-9276
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC32989207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ07301Medicare ID - Type Unspecified
NCF05911Medicare UPIN