Provider Demographics
NPI:1083641476
Name:BLACKBURN, CARL JOSEPH (OD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:JOSEPH
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7619 DOLPHIN ARC DR
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77346-8199
Mailing Address - Country:US
Mailing Address - Phone:713-450-4484
Mailing Address - Fax:713-450-4424
Practice Address - Street 1:5655 E SAM HOUSTON PKWY N
Practice Address - Street 2:A
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77015-3250
Practice Address - Country:US
Practice Address - Phone:713-450-4484
Practice Address - Fax:713-450-4424
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1771TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX158706501Medicaid
U30581Medicare UPIN
TX00729PMedicare ID - Type Unspecified