Provider Demographics
NPI:1538144399
Name:BLACKBURN, MICHAEL D (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:BLACKBURN
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 1:4960 VALLEYDALE RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-4613
Mailing Address - Country:US
Mailing Address - Phone:205-980-5152
Mailing Address - Fax:205-980-5154
Practice Address - Street 1:4960 VALLEYDALE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35242-4613
Practice Address - Country:US
Practice Address - Phone:205-980-5152
Practice Address - Fax:205-980-5154
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS672TA330152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T78341Medicare UPIN