Provider Demographics
NPI:1164440368
Name:BLANKENSHIP, TIMOTHY (OD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:BLANKENSHIP
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 1:1200 W DEYOUNG ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-4437
Mailing Address - Country:US
Mailing Address - Phone:618-993-5686
Mailing Address - Fax:618-997-6250
Practice Address - Street 1:2511 N WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-2338
Practice Address - Country:US
Practice Address - Phone:573-686-5866
Practice Address - Fax:573-686-0425
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006018048152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00434357OtherMEDICARE RAILROAD
MO211780OtherANTHEM BLUE CROSS BLUE SHIELD
MO0814870017OtherMEDICARE NSC NUMBER
MO0814870002OtherMEDICARE NSC NUMBER
MO8048OtherEYEMED
MO0814870015OtherMEDICARE NSC NUMBER
127205OtherHEALTH ALLIANCE
MO310865506Medicaid
MO211780OtherANTHEM BLUE CROSS BLUE SHIELD
MOP00434357OtherMEDICARE RAILROAD