Provider Demographics
NPI:1871618819
Name:BLACKBURN, DAPHNE LORRAINE (MD)
Entity type:Individual
Prefix:DR
First Name:DAPHNE
Middle Name:LORRAINE
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30601-2635
Mailing Address - Country:US
Mailing Address - Phone:762-499-6960
Mailing Address - Fax:
Practice Address - Street 1:485 HUNTINGTON RD
Practice Address - Street 2:SUITE 195
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-1861
Practice Address - Country:US
Practice Address - Phone:706-552-5470
Practice Address - Fax:706-552-5471
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034780207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAA59652Medicare UPIN