Provider Demographics
NPI:1003033119
Name:BLANKENHORN, BRAD D (MD)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:D
Last Name:BLANKENHORN
Suffix:
Gender:M
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:PO BOX 1119
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02901-1119
Mailing Address - Country:US
Mailing Address - Phone:401-330-1405
Mailing Address - Fax:401-277-0799
Practice Address - Street 1:1 KETTLE POINT AVE
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-5375
Practice Address - Country:US
Practice Address - Phone:401-330-1405
Practice Address - Fax:401-277-0799
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2012-0546207X00000X, 207X00000X
RIMD13206207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI110087299AOtherMASSHEALTH
RIBB81009Medicaid
RIBB81009Medicaid