Individual
DR. DEMETRIOUS J. BLACKMON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
250 VILLAGE CENTER PWKY, SUITE 100, STOCKBRIDGE, GA 30281-9044
(678) 289-0508
(678) 289-0124
Mailing address
250 VILLAGE CENTER PKWY, SUITE 100, STOCKBRIDGE, GA 30281-9104
(678) 289-0508
(678) 289-0124
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
MD38696
TN
207RN0300X
Nephrology Physician
Primary
57778
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
009934159
—
AL
05
—
3334458
—
TN
05
—
3334459
—
TN
01
—
4111806
BCBS OF TENNESSEE
TN
01
—
4152444
BLUE CROSS
TN
01
—
581365705
CHAMPUS
GA
05
—
662769049A
—
GA
05
—
662769049F
—
GA
01
—
P00254515
RAILROAD MEDICARE
TN
Enumeration date
06/30/2006
Last updated
03/04/2015
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