Healthcare Provider Details

I. General information

NPI: 1710079819
Provider Name (Legal Business Name): DARRELL KEVIN BLACKWELL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 01/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1490 PARK AVE NW SUITE 5
NORTON VA
24273-1631
US

IV. Provider business mailing address

1490 PARK AVE NW SUITE 5
NORTON VA
24273-1631
US

V. Phone/Fax

Practice location:
  • Phone: 276-439-1440
  • Fax: 276-439-1441
Mailing address:
  • Phone: 276-439-1440
  • Fax: 276-439-1441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number0102050073
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0102050073
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: