Provider Demographics
NPI:1346306651
Name:BLITZ, DONALD R (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:R
Last Name:BLITZ
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 1:25865 W 12 MILE RD
Mailing Address - Street 2:SUITE A101
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1817
Mailing Address - Country:US
Mailing Address - Phone:248-948-1990
Mailing Address - Fax:248-948-9158
Practice Address - Street 1:25865 W 12 MILE RD
Practice Address - Street 2:SUITE A101
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1817
Practice Address - Country:US
Practice Address - Phone:248-948-1990
Practice Address - Fax:248-948-9158
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301033807207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B42944Medicare UPIN
06335491161Medicare ID - Type Unspecified