Provider Demographics
NPI:1952789729
Name:RAYMOND C. BLACKBURN, M.D.
Entity Type:Organization
Organization Name:RAYMOND C. BLACKBURN, M.D.
Other - Org Name:RAYMOND C. BLACKBURN, M.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:C
Authorized Official - Last Name:BLACKBURN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-630-5256
Mailing Address - Street 1:8200 BROOKRIVER DR
Mailing Address - Street 2:SUITE N705
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75247-4069
Mailing Address - Country:US
Mailing Address - Phone:214-630-5256
Mailing Address - Fax:
Practice Address - Street 1:8200 BROOKRIVER DR
Practice Address - Street 2:SUITE N705
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75247-4069
Practice Address - Country:US
Practice Address - Phone:214-630-5256
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-13
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF2557207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC13504Medicare UPIN