Provider Demographics
NPI:1265429849
Name:BLASCHKE, JEROME THOMAS (OD)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:THOMAS
Last Name:BLASCHKE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 WAYZATA BLVD E
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-1963
Mailing Address - Country:US
Mailing Address - Phone:952-473-7505
Mailing Address - Fax:952-473-9880
Practice Address - Street 1:1160 WAYZATA BLVD E
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-1963
Practice Address - Country:US
Practice Address - Phone:952-473-7505
Practice Address - Fax:952-473-9880
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1926152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T39701Medicare UPIN
410000119Medicare ID - Type Unspecified