Provider Demographics
NPI:1851344014
Name:BLYDEN, GERSHWIN THEOPHILUS (MD)
Entity Type:Individual
Prefix:DR
First Name:GERSHWIN
Middle Name:THEOPHILUS
Last Name:BLYDEN
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 1:8335 NE 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33138-3810
Mailing Address - Country:US
Mailing Address - Phone:305-757-0113
Mailing Address - Fax:305-756-7485
Practice Address - Street 1:8335 NE 2ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33138-3810
Practice Address - Country:US
Practice Address - Phone:305-757-0113
Practice Address - Fax:305-756-7485
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0048415207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL044049300Medicaid
FLD50341Medicare UPIN
FL02117Medicare ID - Type Unspecified