Provider Demographics
NPI:1891893731
Name:BLEZA, ROBERT DALE (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DALE
Last Name:BLEZA
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:PO BOX 728
Mailing Address - Street 2:
Mailing Address - City:SCHERERVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46375-0728
Mailing Address - Country:US
Mailing Address - Phone:219-663-8110
Mailing Address - Fax:219-663-8115
Practice Address - Street 1:303 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:IN
Practice Address - Zip Code:46714-2503
Practice Address - Country:US
Practice Address - Phone:260-353-2021
Practice Address - Fax:260-479-2990
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010145671A174400000X
IN01045671A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00881327OtherRAILROAD MEDICARE
IN201011620AMedicaid
IN264810AMedicare PIN
IN201011620AMedicaid