Provider Demographics
NPI:1568554137
Name:BLACKERBY, TIMOTHY (DPM)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:
Last Name:BLACKERBY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5415 TREAT HWY
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221
Mailing Address - Country:US
Mailing Address - Phone:517-263-5813
Mailing Address - Fax:
Practice Address - Street 1:5415 TREAT HWY
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221
Practice Address - Country:US
Practice Address - Phone:517-263-5813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL651126213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist