Provider Demographics
NPI:1619059516
Name:BLODGETT, THOMAS P (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:P
Last Name:BLODGETT
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 1:39 HIDDEN VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:BIDWELL
Mailing Address - State:OH
Mailing Address - Zip Code:45614-9591
Mailing Address - Country:US
Mailing Address - Phone:740-446-7623
Mailing Address - Fax:740-446-7643
Practice Address - Street 1:39 HIDDEN VALLEY DR
Practice Address - Street 2:
Practice Address - City:BIDWELL
Practice Address - State:OH
Practice Address - Zip Code:45614-9591
Practice Address - Country:US
Practice Address - Phone:740-446-7623
Practice Address - Fax:740-446-7643
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35073950B207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2065394Medicaid
OH2065394Medicaid