Provider Demographics
NPI:1477846699
Name:BLANFORD, THEODORE JOSEPH-DOUGLAS (HIS)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:JOSEPH-DOUGLAS
Last Name:BLANFORD
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:927 E DUPONT RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1551
Mailing Address - Country:US
Mailing Address - Phone:260-338-2942
Mailing Address - Fax:260-338-2504
Practice Address - Street 1:927 E DUPONT RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1551
Practice Address - Country:US
Practice Address - Phone:260-338-2942
Practice Address - Fax:260-338-2504
Is Sole Proprietor?:No
Enumeration Date:2011-05-20
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN17001362A237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist