Healthcare Provider Details

I. General information

NPI: 1407987076
Provider Name (Legal Business Name): ROBERT CHARLES BLACKMON IV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3720 MARTIN LUTHER KING JR AVE SE
WASHINGTON DC
20032-1548
US

IV. Provider business mailing address

PO BOX 2948
WASHINGTON DC
20013-2948
US

V. Phone/Fax

Practice location:
  • Phone: 202-561-4190
  • Fax:
Mailing address:
  • Phone: 660-232-1857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberMD035847
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: