Provider Demographics
NPI:1366413437
Name:BLACKBURN, MARI (DO)
Entity type:Individual
Prefix:
First Name:MARI
Middle Name:
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7801 YORK RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-7446
Mailing Address - Country:US
Mailing Address - Phone:410-769-4920
Mailing Address - Fax:410-296-4205
Practice Address - Street 1:7801 YORK RD
Practice Address - Street 2:SUITE 102
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-7446
Practice Address - Country:US
Practice Address - Phone:410-769-4920
Practice Address - Fax:410-296-4205
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH45300207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
8895LC348OtherMEDICARE PROVIDER NUMBER
8895LC348OtherMEDICARE PROVIDER NUMBER