Provider Demographics
NPI:1386925170
Name:BLACKBURN, VAUGHN DANIEL (DPM)
Entity type:Individual
Prefix:DR
First Name:VAUGHN
Middle Name:DANIEL
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 PLEASANT AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-4670
Mailing Address - Country:US
Mailing Address - Phone:513-829-9333
Mailing Address - Fax:513-858-7827
Practice Address - Street 1:5 W MAIN ST
Practice Address - Street 2:
Practice Address - City:AMELIA
Practice Address - State:OH
Practice Address - Zip Code:45102-1924
Practice Address - Country:US
Practice Address - Phone:513-753-0500
Practice Address - Fax:513-986-0218
Is Sole Proprietor?:No
Enumeration Date:2011-09-07
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003708213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0119172Medicaid
KY7100441710Medicaid
IN201371230Medicaid
IN201371230Medicaid
OHH320816Medicare PIN
OHH363961Medicare PIN