Provider Demographics
NPI:1134549884
Name:BLACKMON, AMY (MD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:BLACKMON
Suffix:
Gender:F
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 10069
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0069
Mailing Address - Country:US
Mailing Address - Phone:909-335-4188
Mailing Address - Fax:
Practice Address - Street 1:1600 E CITRUS AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-4270
Practice Address - Country:US
Practice Address - Phone:909-794-3682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-21
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA144585207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine