Provider Demographics
NPI:1760461263
Name:BLICKENSDERFER, E DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:E
Middle Name:DAVID
Last Name:BLICKENSDERFER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2760
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57709-2760
Mailing Address - Country:US
Mailing Address - Phone:605-343-1333
Mailing Address - Fax:605-343-6017
Practice Address - Street 1:353 FAIRMONT BLVD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7375
Practice Address - Country:US
Practice Address - Phone:605-343-1333
Practice Address - Fax:605-343-6017
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD3704207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5707050Medicaid
SD0002907OtherWELLMARK NUMBER
SD050025368OtherRAILROAD MEDICARE
SD050025368OtherRAILROAD MEDICARE
SDS2907Medicare PIN