Provider Demographics
NPI:1629315353
Name:BLODA, MARTIN (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:BLODA
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 1:1576 MARYLAND CLUB DR
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-4501
Mailing Address - Country:US
Mailing Address - Phone:248-670-4790
Mailing Address - Fax:
Practice Address - Street 1:34336 HARPER AVE
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035-3704
Practice Address - Country:US
Practice Address - Phone:586-791-9173
Practice Address - Fax:586-791-9393
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301092346208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice