Provider Demographics
NPI:1881657823
Name:BLUE, JR, JOHN FREDRICK (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:FREDRICK
Last Name:BLUE, JR
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 1:719 N VANCE ST
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-3449
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 MORVEN RD
Practice Address - Street 2:
Practice Address - City:WADESBORO
Practice Address - State:NC
Practice Address - Zip Code:28170-2745
Practice Address - Country:US
Practice Address - Phone:800-893-9698
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23831207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89131HTMedicaid
NC89131HTMedicaid
NCC87387Medicare UPIN