Basic Information
| Provider Information | |||||||||
| NPI: | 1386058469 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DI BLASI | ||||||||
| FirstName: | JOHNNY | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1016 LIBERTY PARK DR | ||||||||
| Address2: | |||||||||
| City: | BRASELTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305171884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044829673 | ||||||||
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| Practice Location | |||||||||
| Address1: | 127 NORTH ST | ||||||||
| Address2: | |||||||||
| City: | BATAVIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140201631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853436030 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2014 | ||||||||
| LastUpdateDate: | 11/15/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 075206 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.