Provider Demographics
NPI:1124025101
Name:BLACKBURN, WILLIAM E (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:E
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1760 NICHOLASVILLE RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1471
Mailing Address - Country:US
Mailing Address - Phone:859-277-5766
Mailing Address - Fax:859-277-3406
Practice Address - Street 1:1760 NICHOLASVILLE RD
Practice Address - Street 2:SUITE 301
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1471
Practice Address - Country:US
Practice Address - Phone:859-277-5766
Practice Address - Fax:859-277-3406
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY15471208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64154719Medicaid
KYC73535Medicare UPIN
KY1275604Medicare PIN