Provider Demographics
NPI:1104357912
Name:BLODI, FREDERICK ROYCE (DO)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:ROYCE
Last Name:BLODI
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 1:5901 WESTOWN PKWY
Mailing Address - Street 2:STE 200
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-8207
Mailing Address - Country:US
Mailing Address - Phone:515-988-4223
Mailing Address - Fax:
Practice Address - Street 1:5901 WESTOWN PKWY STE 200
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-8222
Practice Address - Country:US
Practice Address - Phone:515-225-3546
Practice Address - Fax:515-224-5946
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-23
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADO-05787207W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program