Provider Demographics
NPI:1023014420
Name:BRENGLE, BLAIR (MD)
Entity Type:Individual
Prefix:
First Name:BLAIR
Middle Name:
Last Name:BRENGLE
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 1:8803 N MERIDIAN STREET
Mailing Address - Street 2:SUITE 350
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260
Mailing Address - Country:US
Mailing Address - Phone:317-252-1219
Mailing Address - Fax:
Practice Address - Street 1:8803 N MERIDIAN STREET
Practice Address - Street 2:SUITE 350
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260
Practice Address - Country:US
Practice Address - Phone:317-252-1219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01043339207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
673660AMedicare ID - Type Unspecified
IN57048Medicare UPIN