Provider Demographics
NPI:1255687554
Name:BLACKBURN, THOMAS IV (OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:BLACKBURN
Suffix:IV
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 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:215 LAUCHWOOD DR STE A
Practice Address - Street 2:
Practice Address - City:LAURINBURG
Practice Address - State:NC
Practice Address - Zip Code:28352-4647
Practice Address - Country:US
Practice Address - Phone:910-276-1993
Practice Address - Fax:910-277-7364
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002173152W00000X
NC2319152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCH470HMedicare PIN
NCNCH470GMedicare PIN
NCNCH470IMedicare PIN
NCNCH470AMedicare PIN
NCH470EMedicare PIN
VAVV7690BMedicare PIN
NCNCH470BMedicare PIN
NCNCH470CMedicare PIN
NCNCH470DMedicare PIN
NCNCH470FMedicare PIN