Provider Demographics
NPI:1750599742
Name:BLACKMON, JOSHUA MARION (MD)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:MARION
Last Name:BLACKMON
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 1409
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31502-1409
Mailing Address - Country:US
Mailing Address - Phone:800-841-4236
Mailing Address - Fax:
Practice Address - Street 1:2000 DAN PROCTOR DR
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-3810
Practice Address - Country:US
Practice Address - Phone:800-841-4236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001865208D00000X
GA636322085R0202X
FLME1105822085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice