Provider Demographics
NPI:1972688729
Name:BLACKMON, WAYNE DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:DOUGLAS
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 1:3000 CONNECTICUT AVE NW
Mailing Address - Street 2:SUITE 310
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20008-2509
Mailing Address - Country:US
Mailing Address - Phone:202-518-9219
Mailing Address - Fax:
Practice Address - Street 1:3000 CONNECTICUT AVE NW
Practice Address - Street 2:SUITE 310
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20008-2509
Practice Address - Country:US
Practice Address - Phone:202-518-9219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD121882084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry