Provider Demographics
NPI:1497759369
Name:BLANKENHORN, GLENN D III (DO)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:D
Last Name:BLANKENHORN
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3300 BAILEY ST NW
Mailing Address - Street 2:STE 104
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646-3613
Mailing Address - Country:US
Mailing Address - Phone:330-837-3823
Mailing Address - Fax:330-837-8313
Practice Address - Street 1:3300 BAILEY ST NW
Practice Address - Street 2:STE 104
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-3613
Practice Address - Country:US
Practice Address - Phone:330-837-3823
Practice Address - Fax:330-837-8313
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH34003712204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0586852Medicaid
OH0586852Medicaid
OHA15829Medicare UPIN