Provider Demographics
NPI:1114929361
Name:BLASDELL, STEVEN CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:CHARLES
Last Name:BLASDELL
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 1:3300 HIGH ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-3321
Mailing Address - Country:US
Mailing Address - Phone:757-673-5680
Mailing Address - Fax:757-397-0236
Practice Address - Street 1:3300 HIGH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-3321
Practice Address - Country:US
Practice Address - Phone:757-673-5680
Practice Address - Fax:757-397-0236
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101039494174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006498507Medicaid
VAB05150Medicare UPIN
VA200000189Medicare ID - Type Unspecified
VA006498507Medicaid