Provider Demographics
NPI:1053399543
Name:BLANKSON, MARY LARTEY (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:LARTEY
Last Name:BLANKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 AVENUE E
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35218-1543
Mailing Address - Country:US
Mailing Address - Phone:205-788-3321
Mailing Address - Fax:205-241-5260
Practice Address - Street 1:1700 AVENUE E
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35218-1543
Practice Address - Country:US
Practice Address - Phone:205-788-3321
Practice Address - Fax:205-241-5260
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00011805208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL303739090Medicaid
AL051516611OtherBLUE CROSS BLUE SHIELD
AL051516611OtherBLUE CROSS BLUE SHIELD