Provider Demographics
NPI:1144217092
Name:BLODGETT, DAVID W (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:W
Last Name:BLODGETT
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 6068
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-0068
Mailing Address - Country:US
Mailing Address - Phone:402-484-9000
Mailing Address - Fax:402-483-4223
Practice Address - Street 1:1710 S 70TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-1676
Practice Address - Country:US
Practice Address - Phone:402-484-9000
Practice Address - Fax:402-483-4223
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE30073207WX0200X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE30073OtherSTATE LICENSE
H19253Medicare UPIN
MI4195044Medicaid