Provider Demographics
NPI:1972653269
Name:BLACKMORE, JONATHAN C (DO)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:C
Last Name:BLACKMORE
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 187
Mailing Address - Street 2:
Mailing Address - City:FAISON
Mailing Address - State:NC
Mailing Address - Zip Code:28341-0187
Mailing Address - Country:US
Mailing Address - Phone:910-267-2042
Mailing Address - Fax:855-996-9090
Practice Address - Street 1:412 SOUTH EAST CENTER ST
Practice Address - Street 2:
Practice Address - City:FAISON
Practice Address - State:NC
Practice Address - Zip Code:28341
Practice Address - Country:US
Practice Address - Phone:910-267-1942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200500942207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1489881Medicaid