Provider Demographics
NPI:1528350485
Name:BLACKBURN, COREY S (DPM)
Entity type:Individual
Prefix:DR
First Name:COREY
Middle Name:S
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5823
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68802-5823
Mailing Address - Country:US
Mailing Address - Phone:308-646-0077
Mailing Address - Fax:308-646-0317
Practice Address - Street 1:1932 ASPEN CIR STE A
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-2474
Practice Address - Country:US
Practice Address - Phone:308-646-0077
Practice Address - Fax:308-646-0317
Is Sole Proprietor?:No
Enumeration Date:2011-05-11
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE341213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1528350485OtherNPI