Provider Demographics
NPI:1790142461
Name:BLACKBURN, GILDEN (MD)
Entity Type:Individual
Prefix:
First Name:GILDEN
Middle Name:
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 1:8131 OLD BROCK RD
Mailing Address - Street 2:
Mailing Address - City:BROCK
Mailing Address - State:TX
Mailing Address - Zip Code:76087-6500
Mailing Address - Country:US
Mailing Address - Phone:817-565-5255
Mailing Address - Fax:
Practice Address - Street 1:8131 OLD BROCK RD
Practice Address - Street 2:
Practice Address - City:BROCK
Practice Address - State:TX
Practice Address - Zip Code:76087-6500
Practice Address - Country:US
Practice Address - Phone:817-565-5255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-26
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.038079207V00000X
TXAM00007207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics