Provider Demographics
NPI:1396887485
Name:BLODGETT, ANDREW DEATON (DO)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:DEATON
Last Name:BLODGETT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-316-1750
Mailing Address - Fax:704-316-1755
Practice Address - Street 1:19830 ZION AVE
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-8495
Practice Address - Country:US
Practice Address - Phone:704-384-1782
Practice Address - Fax:704-384-1783
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC2006-00275207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5908164Medicaid
NC2075802AMedicare PIN
NC2075802Medicare PIN