1164404588 NPI number — DR. CALVIN L BLOUNT JR. M.D.

Table of content: DR. CALVIN L BLOUNT JR. M.D. (NPI 1164404588)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164404588 NPI number — DR. CALVIN L BLOUNT JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLOUNT
Provider First Name:
CALVIN
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164404588
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/18/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4012 COMMONS DR W STE 120
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DESTIN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32541-8424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-424-5474
Provider Business Mailing Address Fax Number:
850-837-6625

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4012 COMMONS DR W STE 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DESTIN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32541-8424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-424-5474
Provider Business Practice Location Address Fax Number:
850-837-6625
Provider Enumeration Date:
11/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  ME76428 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 255279500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: ME76428 . This is a "STATE LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 5903676 . This is a "AETNA INSURANCE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 593553504 . This is a "CHAMPUS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 593553504 . This is a "GREAT WEST" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 080146219 . This is a "MDC RAILROAD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 44250 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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