Provider Demographics
NPI:1801328125
Name:BLANKSHAIN, KIMBERLY DIANE (MD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DIANE
Last Name:BLANKSHAIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2015 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-3190
Mailing Address - Country:US
Mailing Address - Phone:630-668-8250
Mailing Address - Fax:630-668-8916
Practice Address - Street 1:2015 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-3190
Practice Address - Country:US
Practice Address - Phone:630-668-8250
Practice Address - Fax:630-668-8916
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-28
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036155745207W00000X, 207WX0109X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0109XAllopathic & Osteopathic PhysiciansOphthalmologyNeuro-ophthalmology
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology