Basic Information
| Provider Information | |||||||||
| NPI: | 1336196815 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACKBURN | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 CONN TER STE 550 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405083206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593235867 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 110 CONN TER STE 550 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405083206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593235867 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 09/13/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 36686 | KY | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207WX0108X | 36686 | KY | N | 207WX0107X | 36686 | KY | Y |
ID Information
| ID | Type | State | Issuer | Description | BB7297232 | 01 | KY | DEA | OTHER | 64030489 | 05 | KY | MEDICAID |