Healthcare Provider Details

I. General information

NPI: 1063750891
Provider Name (Legal Business Name): DEBORAH J BLANTON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2013
Last Update Date: 01/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13947 BEACH BLVD STE 202
JACKSONVILLE FL
32224-1200
US

IV. Provider business mailing address

101 N MILL RIDGE TRL
PONTE VEDRA BEACH FL
32082-5112
US

V. Phone/Fax

Practice location:
  • Phone: 904-223-1771
  • Fax:
Mailing address:
  • Phone: 904-543-1991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License NumberME45016
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: