Healthcare Provider Details

I. General information

NPI: 1619059516
Provider Name (Legal Business Name): THOMAS P BLODGETT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 04/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 HIDDEN VALLEY DR
BIDWELL OH
45614-9591
US

IV. Provider business mailing address

39 HIDDEN VALLEY DR
BIDWELL OH
45614-9591
US

V. Phone/Fax

Practice location:
  • Phone: 740-446-7623
  • Fax: 740-446-7643
Mailing address:
  • Phone: 740-446-7623
  • Fax: 740-446-7643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number35073950B
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: