Healthcare Provider Details

I. General information

NPI: 1346306651
Provider Name (Legal Business Name): DONALD R BLITZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25865 W 12 MILE RD SUITE A101
SOUTHFIELD MI
48034-1817
US

IV. Provider business mailing address

25865 W 12 MILE RD SUITE A101
SOUTHFIELD MI
48034-1817
US

V. Phone/Fax

Practice location:
  • Phone: 248-948-1990
  • Fax: 248-948-9158
Mailing address:
  • Phone: 248-948-1990
  • Fax: 248-948-9158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number4301033807
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: