Provider Demographics
NPI:1861403313
Name:BLACKMON-DAVIS, VICKI A (MD)
Entity type:Individual
Prefix:MRS
First Name:VICKI
Middle Name:A
Last Name:BLACKMON-DAVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 360541
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15251-6541
Mailing Address - Country:US
Mailing Address - Phone:972-525-9900
Mailing Address - Fax:469-333-7988
Practice Address - Street 1:1020 N COLLINS ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76011-6134
Practice Address - Country:US
Practice Address - Phone:972-525-9900
Practice Address - Fax:469-333-7988
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9213173000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX80W790Medicare PIN