Provider Demographics
NPI:1033162169
Name:GLENDA LOPEZ-BLAZA MD, LLC
Entity Type:Organization
Organization Name:GLENDA LOPEZ-BLAZA MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:LOPEZ-BLAZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-415-0501
Mailing Address - Street 1:8710 N DIXIE DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-2406
Mailing Address - Country:US
Mailing Address - Phone:937-415-0501
Mailing Address - Fax:937-415-0520
Practice Address - Street 1:8710 N DIXIE DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-2406
Practice Address - Country:US
Practice Address - Phone:937-415-0501
Practice Address - Fax:937-415-0520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0983002Medicaid
OH2988272Medicaid
OH2988272Medicaid
OH9332091Medicare PIN