Provider Demographics
NPI:1316907629
Name:BLACKBURN, ROY M (MD)
Entity type:Individual
Prefix:MR
First Name:ROY
Middle Name:M
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 849095
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-9095
Mailing Address - Country:US
Mailing Address - Phone:541-344-8469
Mailing Address - Fax:541-687-8631
Practice Address - Street 1:2401 RIVER ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97404
Practice Address - Country:US
Practice Address - Phone:541-344-8469
Practice Address - Fax:541-687-8631
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD22132208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
F57403Medicare UPIN
OR5M774Medicare ID - Type Unspecified