Provider Demographics
NPI:1598919409
Name:BLACKBURN, MARCUS KIM (MD)
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:KIM
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MARIO CAPECCHI DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84112-8924
Mailing Address - Country:US
Mailing Address - Phone:801-662-5702
Mailing Address - Fax:
Practice Address - Street 1:100 MARIO CAPECCHI DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-8924
Practice Address - Country:US
Practice Address - Phone:801-662-5702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-06
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7148440-1205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics