Provider Demographics
NPI:1073860441
Name:BLYSTRA, ADAM CALVIN (DO)
Entity Type:Individual
Prefix:DR
First Name:ADAM
Middle Name:CALVIN
Last Name:BLYSTRA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10401 W THUNDERBIRD BLVD
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85351-3004
Mailing Address - Country:US
Mailing Address - Phone:623-832-5772
Mailing Address - Fax:
Practice Address - Street 1:10401 W THUNDERBIRD BLVD
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-3004
Practice Address - Country:US
Practice Address - Phone:623-832-5772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-05
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP5597390200000X, 207P00000X
AZ006363207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program