Provider Demographics
NPI:1336200617
Name:BLIESE, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BLIESE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2317 BAINBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755
Mailing Address - Country:US
Mailing Address - Phone:573-243-6719
Mailing Address - Fax:573-243-6719
Practice Address - Street 1:2317 BAINBRIDGE RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MO
Practice Address - Zip Code:63755-2343
Practice Address - Country:US
Practice Address - Phone:573-243-6719
Practice Address - Fax:573-243-6719
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO2706152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO312308604Medicaid
MO312308604Medicaid
MOT42615Medicare UPIN