Provider Demographics
NPI:1356333967
Name:LOPEZ-BLAZA, GLENDA JOY (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENDA
Middle Name:JOY
Last Name:LOPEZ-BLAZA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8710 N DIXIE DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-2406
Mailing Address - Country:US
Mailing Address - Phone:937-415-0501
Mailing Address - Fax:937-415-0520
Practice Address - Street 1:8710 N DIXIE DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-2406
Practice Address - Country:US
Practice Address - Phone:937-415-0501
Practice Address - Fax:937-415-0520
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-19
Last Update Date:2010-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-05-0692-L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0983002Medicaid
E33901Medicare UPIN
OH0983002Medicaid