Provider Demographics
NPI:1538768833
Name:WELDON, JAMES BLAKE (IDC)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:BLAKE
Last Name:WELDON
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:TROUT AVE
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340
Mailing Address - Country:US
Mailing Address - Phone:860-694-2876
Mailing Address - Fax:
Practice Address - Street 1:UNIT 100517 BX 1
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:09655
Practice Address - Country:US
Practice Address - Phone:207-438-1010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman