Healthcare Provider Details

I. General information

NPI: 1649381468
Provider Name (Legal Business Name): JONATHAN WILLIAM BLANK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 10/24/2022
Certification Date: 10/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2430 EMERALD PL STE 201
GREENVILLE NC
27834-5743
US

IV. Provider business mailing address

2430 EMERALD PL STE 201
GREENVILLE NC
27834-5743
US

V. Phone/Fax

Practice location:
  • Phone: 252-752-2140
  • Fax:
Mailing address:
  • Phone: 252-752-2140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number32991
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number32991
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: