Provider Demographics
NPI:1790769701
Name:BLAIR, JERRY R (MD, PHD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:R
Last Name:BLAIR
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 AMRON CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65202-1918
Mailing Address - Country:US
Mailing Address - Phone:573-874-1616
Mailing Address - Fax:573-875-0300
Practice Address - Street 1:3600 AMRON CT
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65202-1918
Practice Address - Country:US
Practice Address - Phone:573-874-1616
Practice Address - Fax:573-875-0300
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108058207WX0107X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207965708Medicaid
5388OtherBLUE CROSS BLUE SHIELD
F12489Medicare UPIN
5388OtherBLUE CROSS BLUE SHIELD
KSH527872Medicare PIN
990001187Medicare ID - Type Unspecified