Healthcare Provider Details

I. General information

NPI: 1154346278
Provider Name (Legal Business Name): RONALD D BLACKSTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 11/16/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2165 N DECATUR RD
DECATUR GA
30033-5307
US

IV. Provider business mailing address

2165 N DECATUR RD
DECATUR GA
30033-5307
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-8553
  • Fax:
Mailing address:
  • Phone: 404-778-8553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number011740
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: