Healthcare Provider Details

I. General information

NPI: 1144640533
Provider Name (Legal Business Name): KYLE BLACKBURN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2014
Last Update Date: 05/18/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 HARRY HINES BLVD GRADUATE MEDICAL EDUCATION
DALLAS TX
75235-7708
US

IV. Provider business mailing address

PO BOX 660599
DALLAS TX
75266-0599
US

V. Phone/Fax

Practice location:
  • Phone: 214-590-8058
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberR6747
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: