Basic Information
| Provider Information | |||||||||
| NPI: | 1811213572 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACKBURN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9101 | ||||||||
| Address2: | |||||||||
| City: | COPPELL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750199494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727457500 | ||||||||
| FaxNumber: | 9727454336 | ||||||||
| Practice Location | |||||||||
| Address1: | 3520 NW CENTRE DR | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761353612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173752100 | ||||||||
| FaxNumber: | 8172370022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2010 | ||||||||
| LastUpdateDate: | 05/29/2014 | ||||||||
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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 | 207Q00000X | N5512 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.