Healthcare Provider Details

I. General information

NPI: 1407895014
Provider Name (Legal Business Name): MR. DAVID A BLISSENBACH
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N 8TH ST
E ST LOUIS IL
62201-2989
US

IV. Provider business mailing address

19 DELANO DR
CAHOKIA IL
62206-3105
US

V. Phone/Fax

Practice location:
  • Phone: 618-274-2020
  • Fax:
Mailing address:
  • Phone: 618-337-1500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: