Provider Demographics
NPI:1881666402
Name:BLANTON, KEVIN J (DO)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:J
Last Name:BLANTON
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:PO BOX 72
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:TX
Mailing Address - Zip Code:76634-0072
Mailing Address - Country:US
Mailing Address - Phone:254-675-8621
Mailing Address - Fax:254-675-2254
Practice Address - Street 1:201 POSEY AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:TX
Practice Address - Zip Code:76634-1200
Practice Address - Country:US
Practice Address - Phone:254-675-8621
Practice Address - Fax:254-675-2254
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7314207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164753904Medicaid
TXF0131015OtherDPS
TX164753904Medicaid
P00256188Medicare PIN
TX8D4820Medicare PIN
I02211Medicare UPIN
TXF0131015OtherDPS