Provider Demographics
NPI:1467896258
Name:BLACKBURN, GARY ROBERT
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:ROBERT
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14098 MEADOW LAKE DR
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-5587
Mailing Address - Country:US
Mailing Address - Phone:317-774-0969
Mailing Address - Fax:317-774-5741
Practice Address - Street 1:501 S 9TH ST
Practice Address - Street 2:SUITE 17
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-2717
Practice Address - Country:US
Practice Address - Phone:317-774-0969
Practice Address - Fax:317-774-5741
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-23
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies