Provider Demographics
NPI:1568647618
Name:BLAIR, NICOLE (MD)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:BLAIR
Suffix:
Gender:F
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:PO BOX 987
Mailing Address - Street 2:21 ORCHARD STREET
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940
Mailing Address - Country:US
Mailing Address - Phone:845-343-7614
Mailing Address - Fax:845-343-5390
Practice Address - Street 1:10 BENTON AVENUE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940
Practice Address - Country:US
Practice Address - Phone:845-343-8838
Practice Address - Fax:845-343-7017
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY246782207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00355931Medicaid
NYW04883PBMedicare PIN
NY00355931Medicaid