Provider Demographics
NPI:1558467431
Name:BLACKBURN, RICHARD E (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:E
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2868 MAHAN DR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5468
Mailing Address - Country:US
Mailing Address - Phone:850-942-7177
Mailing Address - Fax:850-656-9443
Practice Address - Street 1:2868 MAHAN DR
Practice Address - Street 2:SUITE 5
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5468
Practice Address - Country:US
Practice Address - Phone:850-942-7177
Practice Address - Fax:850-656-9443
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME612052084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE34777Medicare UPIN