Provider Demographics
NPI:1164428207
Name:BLITZER, MARK L (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:L
Last Name:BLITZER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:330 ORCHARD ST.
Mailing Address - Street 2:SUITE 210
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-4429
Mailing Address - Country:US
Mailing Address - Phone:203-867-5400
Mailing Address - Fax:203-867-5401
Practice Address - Street 1:330 ORCHARD ST.
Practice Address - Street 2:SUITE 210
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-4429
Practice Address - Country:US
Practice Address - Phone:203-867-5400
Practice Address - Fax:203-867-5401
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2013-07-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CT037730174400000X, 207RC0000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTG55650Medicare UPIN