Provider Demographics
NPI:1740260652
Name:BLANK, WILLIAM F JR
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:F
Last Name:BLANK
Suffix:JR
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 1:221 S MAIN ST
Mailing Address - Street 2:PO BOX 216
Mailing Address - City:CHAFFEE
Mailing Address - State:MO
Mailing Address - Zip Code:63740-1040
Mailing Address - Country:US
Mailing Address - Phone:573-887-3632
Mailing Address - Fax:573-887-3635
Practice Address - Street 1:221 S MAIN
Practice Address - Street 2:
Practice Address - City:CHAFFEE
Practice Address - State:MO
Practice Address - Zip Code:63740
Practice Address - Country:US
Practice Address - Phone:573-887-3632
Practice Address - Fax:573-887-3635
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO34699207ZD0900X
IL207ZD0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A10261Medicare UPIN