Provider Demographics
NPI:1811213572
Name:BLACKBURN, MATTHEW LEE (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LEE
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9101
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-9494
Mailing Address - Country:US
Mailing Address - Phone:972-745-7500
Mailing Address - Fax:972-745-4336
Practice Address - Street 1:3520 NW CENTRE DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-3612
Practice Address - Country:US
Practice Address - Phone:817-375-2100
Practice Address - Fax:817-237-0022
Is Sole Proprietor?:No
Enumeration Date:2010-04-20
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN5512207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB112305Medicare PIN