Healthcare Provider Details

I. General information

NPI: 1164605333
Provider Name (Legal Business Name): DAVID BLIKLEN, M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2007
Last Update Date: 01/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5757 W THUNDERBIRD RD SUITE E151
GLENDALE AZ
85306-4685
US

IV. Provider business mailing address

5757 W THUNDERBIRD RD SUITE E 151
GLENDALE AZ
85306-4641
US

V. Phone/Fax

Practice location:
  • Phone: 602-843-3811
  • Fax: 602-843-0044
Mailing address:
  • Phone: 602-843-3811
  • Fax: 602-843-0044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number17275
License Number StateAZ

VIII. Authorized Official

Name: DR. DAVID BLIKLEN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 602-843-3811