Provider Demographics
NPI:1093777864
Name:BLACKBURN, JOHN DEVIN (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DEVIN
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 1:7409 N CEDAR AVE
Mailing Address - Street 2:#103
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3836
Mailing Address - Country:US
Mailing Address - Phone:559-439-3937
Mailing Address - Fax:559-325-9313
Practice Address - Street 1:7409 N CEDAR AVE
Practice Address - Street 2:#103
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3836
Practice Address - Country:US
Practice Address - Phone:559-439-3937
Practice Address - Fax:559-325-9313
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11297TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0112970Medicaid
CASD0112970Medicare ID - Type Unspecified
CAU81225Medicare UPIN