Provider Demographics
NPI:1427017888
Name:BLACKBURN, WARREN ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:WARREN
Middle Name:ALLEN
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:919-496-5774
Mailing Address - Fax:919-496-2311
Practice Address - Street 1:205 SANDALWOOD AVE
Practice Address - Street 2:SUITE C
Practice Address - City:LOUISBURG
Practice Address - State:NC
Practice Address - Zip Code:27549-2679
Practice Address - Country:US
Practice Address - Phone:919-496-5774
Practice Address - Fax:919-496-2311
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC35585207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8915985Medicaid
F39759Medicare UPIN
NC8915985Medicaid
NC2176240DMedicare PIN