Provider Demographics
NPI:1457421612
Name:BLACKBURN, SEAN G (OD)
Entity Type:Individual
Prefix:DR
First Name:SEAN
Middle Name:G
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:836 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:NE
Mailing Address - Zip Code:69162-1402
Mailing Address - Country:US
Mailing Address - Phone:308-254-5115
Mailing Address - Fax:
Practice Address - Street 1:836 18TH AVE
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:NE
Practice Address - Zip Code:69162-1402
Practice Address - Country:US
Practice Address - Phone:308-254-5115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1066152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE267573Medicare ID - Type Unspecified
NE1121550001Medicare NSC
NEU57232Medicare UPIN