Provider Demographics
NPI:1457945412
Name:BLALOCK, PAUL HENRY JR (RDN)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:HENRY
Last Name:BLALOCK
Suffix:JR
Gender:M
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BELLS ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23664-2100
Mailing Address - Country:US
Mailing Address - Phone:702-438-8759
Mailing Address - Fax:
Practice Address - Street 1:501 BUTLER FARM RD STE A
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-1777
Practice Address - Country:US
Practice Address - Phone:757-766-1921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-21
Last Update Date:2021-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered