Provider Demographics
NPI:1407895014
Name:BLISSENBACH, DAVID A
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:A
Last Name:BLISSENBACH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 DELANO DR
Mailing Address - Street 2:
Mailing Address - City:CAHOKIA
Mailing Address - State:IL
Mailing Address - Zip Code:62206-3105
Mailing Address - Country:US
Mailing Address - Phone:618-337-1500
Mailing Address - Fax:
Practice Address - Street 1:100 N 8TH ST
Practice Address - Street 2:
Practice Address - City:E ST LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62201-2989
Practice Address - Country:US
Practice Address - Phone:618-274-2020
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371210755001Medicaid