Healthcare Provider Details

I. General information

NPI: 1467423608
Provider Name (Legal Business Name): JOHN DAVID BLEVINS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 04/19/2023
Certification Date: 04/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 SUNSET BLVD
WEST COLUMBIA SC
29169-4810
US

IV. Provider business mailing address

PO BOX 6069
WEST COLUMBIA SC
29171-6069
US

V. Phone/Fax

Practice location:
  • Phone: 803-936-7372
  • Fax: 803-936-4102
Mailing address:
  • Phone: 803-936-7372
  • Fax: 803-936-4102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number058855
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number86721
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: