Provider Demographics
NPI:1710926985
Name:BLANK, MICHAEL S (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
Last Name:BLANK
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 1:1031 PIERCE STREET
Mailing Address - Street 2:SUITE D
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870
Mailing Address - Country:US
Mailing Address - Phone:419-557-5541
Mailing Address - Fax:419-557-5542
Practice Address - Street 1:1912 HAYES AVE
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-4736
Practice Address - Country:US
Practice Address - Phone:419-557-6780
Practice Address - Fax:419-557-6783
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-08-6360207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2595179Medicaid
I41470Medicare UPIN
OHBL4169001Medicare ID - Type Unspecified
OH2595179Medicaid