1679219752 NPI number — DONALD LEWIS BLOODWORTH III APRN

Table of content: DONALD LEWIS BLOODWORTH III APRN (NPI 1679219752)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679219752 NPI number — DONALD LEWIS BLOODWORTH III APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLOODWORTH
Provider First Name:
DONALD
Provider Middle Name:
LEWIS
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
APRN
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:
1679219752
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 ALBERT CREE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUTLAND
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05701-4674
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-786-1400
Provider Business Mailing Address Fax Number:
802-786-1405

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 ALBERT CREE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUTLAND
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05701-4674
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-786-1400
Provider Business Practice Location Address Fax Number:
802-786-1405
Provider Enumeration Date:
05/11/2022

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: 363LF0000X , with the licence number:  026.0126294 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com