Provider Demographics
NPI:1033175989
Name:BLAHA, DENNIS ROGER (MD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:ROGER
Last Name:BLAHA
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 39179
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85069-9179
Mailing Address - Country:US
Mailing Address - Phone:602-395-0718
Mailing Address - Fax:602-277-8146
Practice Address - Street 1:7600 N 16TH ST
Practice Address - Street 2:SUITE 150
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-4431
Practice Address - Country:US
Practice Address - Phone:602-395-0718
Practice Address - Fax:602-277-8146
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13790207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0050540OtherBX BS OF AZ
AZ046608Medicaid
AZAZ0050540OtherBX BS OF AZ