Provider Demographics
NPI:1477505543
Name:BLICKENSDERFER, JANELLE RUTH (DO)
Entity Type:Individual
Prefix:DR
First Name:JANELLE
Middle Name:RUTH
Last Name:BLICKENSDERFER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 N LAFAYETTE BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1003
Mailing Address - Country:US
Mailing Address - Phone:574-232-2037
Mailing Address - Fax:574-232-1420
Practice Address - Street 1:515 N LAFAYETTE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1003
Practice Address - Country:US
Practice Address - Phone:574-232-2037
Practice Address - Fax:574-232-1420
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001307A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100339290AMedicaid
IN100339290AMedicaid
238760GMedicare ID - Type Unspecified