Provider Demographics
NPI:1396794947
Name:BLAYLOCK, WILLIAM K
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:K
Last Name:BLAYLOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 GRESHAM DR
Mailing Address - Street 2:MEDICAL TOWER, SUITE 702
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1901
Mailing Address - Country:US
Mailing Address - Phone:757-533-5437
Mailing Address - Fax:757-533-5602
Practice Address - Street 1:400 GRESHAM DR
Practice Address - Street 2:MEDICAL TOWER, SUITE 702
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1901
Practice Address - Country:US
Practice Address - Phone:757-533-5437
Practice Address - Fax:757-533-5602
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101044962146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0063-3042-8Medicaid
VA240001577OtherRR MEDICARE
VA099122OtherANTHEM BCBS
VA54-1546268OtherTAX ID
VA180000324Medicare ID - Type Unspecified