Provider Demographics
NPI:1770979874
Name:BLEDSOE, MICHAEL VAUGHN BAXTER (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:VAUGHN BAXTER
Last Name:BLEDSOE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1320 MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RONCEVERTE
Mailing Address - State:WV
Mailing Address - Zip Code:24970-8016
Mailing Address - Country:US
Mailing Address - Phone:304-647-4411
Mailing Address - Fax:
Practice Address - Street 1:1320 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-8016
Practice Address - Country:US
Practice Address - Phone:304-647-4411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-15
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3097207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine