Provider Demographics
NPI:1053593079
Name:BLACKBURN, TAMIKA (MD)
Entity type:Individual
Prefix:DR
First Name:TAMIKA
Middle Name:
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 1:1260 SILAS DEANE HWY STE 103
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-4363
Mailing Address - Country:US
Mailing Address - Phone:860-563-9518
Mailing Address - Fax:860-257-0088
Practice Address - Street 1:1260 SILAS DEANE HWY STE 103
Practice Address - Street 2:
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-4363
Practice Address - Country:US
Practice Address - Phone:860-563-9518
Practice Address - Fax:860-257-0088
Is Sole Proprietor?:No
Enumeration Date:2007-11-30
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY247841207R00000X
CT53376207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine