Provider Demographics
NPI:1710988282
Name:BLAD, DENISE E (MD)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:E
Last Name:BLAD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-458-3212
Mailing Address - Fax:260-458-3214
Practice Address - Street 1:6515 STELLHORN RD STE 200
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-5436
Practice Address - Country:US
Practice Address - Phone:260-458-3212
Practice Address - Fax:260-458-3214
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35084375207Q00000X
IN01052983A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2478279Medicaid
IN200187450Medicaid
IN264430FMedicare PIN
OHBL4133141Medicare PIN
IN144020LMedicare PIN
OH2478279Medicaid