Provider Demographics
NPI:1548223936
Name:BLIKLEN, DAVID A (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:BLIKLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6677 W THUNDERBIRD RD STE D148
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-3769
Mailing Address - Country:US
Mailing Address - Phone:602-843-3811
Mailing Address - Fax:602-843-0044
Practice Address - Street 1:6677 W THUNDERBIRD RD STE D148
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-3769
Practice Address - Country:US
Practice Address - Phone:602-843-3811
Practice Address - Fax:602-843-0044
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ172752084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ273441-01Medicaid
AZ27344101Medicaid
C99158Medicare UPIN
AZZMD17275Medicare ID - Type Unspecified