Provider Demographics
NPI:1972506194
Name:BLACKMON, SUMPTER DUDLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:SUMPTER
Middle Name:DUDLEY
Last Name:BLACKMON
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:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:AL
Mailing Address - Zip Code:36726-0699
Mailing Address - Country:US
Mailing Address - Phone:334-682-4128
Mailing Address - Fax:334-682-9151
Practice Address - Street 1:321 WHISKEY RUN RD
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:AL
Practice Address - Zip Code:36726-2303
Practice Address - Country:US
Practice Address - Phone:334-682-4128
Practice Address - Fax:334-682-9151
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2015-09-15
Deactivation Date:2006-03-15
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
AL5754207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000000454Medicaid
ALC71994Medicare UPIN
AL000000454Medicaid