Provider Demographics
NPI:1639159072
Name:BLANKENBURG, MARK E (MD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:E
Last Name:BLANKENBURG
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 1:25 NORTH F STREET
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45013
Mailing Address - Country:US
Mailing Address - Phone:513-868-1011
Mailing Address - Fax:513-868-6170
Practice Address - Street 1:25 NORTH F STREET
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45013
Practice Address - Country:US
Practice Address - Phone:513-868-1011
Practice Address - Fax:513-868-6170
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50381208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0558427Medicaid
OH0558427Medicaid