Provider Demographics
NPI:1265403547
Name:BLACKWOOD, GEORGE VADEN (DO)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:VADEN
Last Name:BLACKWOOD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2232 HAVERSHAM CLOSE
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-1151
Mailing Address - Country:US
Mailing Address - Phone:747-496-9944
Mailing Address - Fax:747-496-9944
Practice Address - Street 1:2232 HAVERSHAM CLOSE
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-1151
Practice Address - Country:US
Practice Address - Phone:747-496-9944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO695207Q00000X
VA0102201540207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine