Provider Demographics
NPI:1659465011
Name:BLEASE, DWIGHT STEPHEN (DPM)
Entity Type:Individual
Prefix:
First Name:DWIGHT
Middle Name:STEPHEN
Last Name:BLEASE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CUSHING ST
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-1801
Mailing Address - Country:US
Mailing Address - Phone:207-725-2800
Mailing Address - Fax:207-725-5953
Practice Address - Street 1:10 CUSHING ST
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-1801
Practice Address - Country:US
Practice Address - Phone:207-725-2800
Practice Address - Fax:207-725-5953
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEME POD 204213ES0000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MET31402OtherHARVARD
ME010446440OtherTAX ID #
ME000942OtherANTHEM
ME000942OtherANTHEM
MET31402OtherHARVARD