MEDICARE: DR. JON D BLACHLEY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0200X	Critical Care Medicine (Internal Medicine) Physician	E6238	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P01022707	OTHER	TX	RAILROAD

General Provider Information

NPI Number	:	1619984440
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JON D BLACHLEY MD

Provider Business Mailing Address
First Line	:	6415 DELOACHE AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75225-2606
Country	:	US
Telephone Number	:	469-585-5209
Fax Number	:

Provider Business Practice Location Address
First Line	:	6415 DELOACHE AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75225-2606
Country	:	US
Telephone Number	:	469-585-5209
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2006
Last Update Date	:	06/29/2012

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