Provider Demographics
NPI:1942388384
Name:BLUNTZER, MARY ELLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ELLEN
Last Name:BLUNTZER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12810 HILLCREST RD
Mailing Address - Street 2:B-127
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230
Mailing Address - Country:US
Mailing Address - Phone:972-490-7800
Mailing Address - Fax:972-490-7810
Practice Address - Street 1:12810 HILLCREST RD
Practice Address - Street 2:B-127
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230
Practice Address - Country:US
Practice Address - Phone:972-490-7800
Practice Address - Fax:972-490-7810
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG4838207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B21338Medicare UPIN
0050AVMedicare ID - Type Unspecified