Provider Demographics
NPI:1003890179
Name:BLACKLEDGE, FRED (MD)
Entity type:Individual
Prefix:DR
First Name:FRED
Middle Name:
Last Name:BLACKLEDGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 24023
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-4023
Mailing Address - Country:US
Mailing Address - Phone:601-366-1400
Mailing Address - Fax:601-366-8167
Practice Address - Street 1:764 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4617
Practice Address - Country:US
Practice Address - Phone:601-981-3033
Practice Address - Fax:601-982-8132
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS16006208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSH86323Medicare UPIN