Provider Demographics
NPI:1437531829
Name:VAUGHN BLACKBURN DPM LLC
Entity Type:Organization
Organization Name:VAUGHN BLACKBURN DPM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM
Authorized Official - Prefix:
Authorized Official - First Name:VAUGHN
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:BLACKBURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-753-0500
Mailing Address - Street 1:6200 PLEASANT AVE
Mailing Address - Street 2:STE 3
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-4670
Mailing Address - Country:US
Mailing Address - Phone:513-829-9333
Mailing Address - Fax:513-858-7827
Practice Address - Street 1:5 W MAIN ST
Practice Address - Street 2:
Practice Address - City:AMELIA
Practice Address - State:OH
Practice Address - Zip Code:45102-1924
Practice Address - Country:US
Practice Address - Phone:513-753-0500
Practice Address - Fax:513-986-0218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-23
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003708213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0139688Medicaid
KY7100441860Medicaid
IN201368390AMedicaid
OHH363960Medicare PIN
OH0139688Medicaid
KY7100441860Medicaid