=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164404588
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CALVIN L BLOUNT JR. M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2005
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12607 US HIGHWAY 98 W
-----------------------------------------------------
City | MIRAMAR BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32550-6825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-837-4844
-----------------------------------------------------
Fax | 850-837-6625
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4012 COMMONS DR W STE 120
-----------------------------------------------------
City | DESTIN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32541-8424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-837-4844
-----------------------------------------------------
Fax | 850-837-6625
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | ME76428
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------