Healthcare Provider Details

I. General information

NPI: 1235195827
Provider Name (Legal Business Name): WILLIAM S BLAKEMORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2006
Last Update Date: 05/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MARK DR
EDENTON NC
27932-1704
US

IV. Provider business mailing address

PO BOX 1077 101 MARK DR
EDENTON NC
27932-1077
US

V. Phone/Fax

Practice location:
  • Phone: 252-482-7471
  • Fax: 252-482-5465
Mailing address:
  • Phone: 252-482-7471
  • Fax: 252-482-5465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number24730
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number24730
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: