Provider Demographics
NPI:1477502136
Name:JESSUP, DAVID BLACKWELL (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:BLACKWELL
Last Name:JESSUP
Suffix:
Gender:M
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 896206
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-6206
Mailing Address - Country:US
Mailing Address - Phone:252-635-6777
Mailing Address - Fax:252-634-3183
Practice Address - Street 1:1001 NEWMAN RD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-5253
Practice Address - Country:US
Practice Address - Phone:252-635-6777
Practice Address - Fax:252-634-3183
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2548207RC0000X, 207RI0011X
NC2013-02325207RC0000X, 207RI0011X
CODR.0063644207RI0011X
MDD90075207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA82107OtherL&I AND CRIME VICTIMS FOR SJMC
AKMD7029WMedicaid
WAP00194456OtherRAILROAD MEDICARE
WAG8900993OtherMEDICARE PIN FOR PHMG
WA1477502136Medicaid
WA0279973OtherL&I AND CRIME VICTIMS FOR PHMG
WA7503052OtherAETNA
WAA057OtherREGENCE BLUE SHIELD
WAG8896098OtherMEDICARE PIN FOR SJMC
WA8399099Medicaid
WA1477502136Medicaid
WAG8802029Medicare PIN