Provider Demographics
NPI:1083946651
Name:BLISSETT, AMELIA SIMONE (MD)
Entity Type:Individual
Prefix:MRS
First Name:AMELIA
Middle Name:SIMONE
Last Name:BLISSETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 BROADWAY DEPARTMENT OF MANAGED CARE ROOM 2B230
Mailing Address - Street 2:WOODHULL MEDICAL & MENTAL HEALTH CENTER
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206
Mailing Address - Country:US
Mailing Address - Phone:718-963-8000
Mailing Address - Fax:718-630-3122
Practice Address - Street 1:760 BROADWAY
Practice Address - Street 2:WOODHULL MEDICAL & MENTAL HEALTH CENTER
Practice Address - City:BROOKLYN
Practice Address - State:NJ
Practice Address - Zip Code:11206
Practice Address - Country:US
Practice Address - Phone:718-963-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-08
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08706100207V00000X
NY255650207V00000X
PAMD439089207V00000X
DEC1-0009273207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0225169Medicaid
NJ0225169Medicaid