Provider Demographics
NPI:1487769352
Name:BLACKBURN, GARY LEON (MSPT)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:LEON
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 TIERRA DEL REY
Mailing Address - Street 2:SUITE C
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-7875
Mailing Address - Country:US
Mailing Address - Phone:619-656-5102
Mailing Address - Fax:619-656-5143
Practice Address - Street 1:1055 TIERRA DEL REY
Practice Address - Street 2:SUITE C
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-7875
Practice Address - Country:US
Practice Address - Phone:619-656-5102
Practice Address - Fax:619-656-5143
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28897225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT28897AMedicare ID - Type Unspecified
CABP191WMedicare PIN