Provider Demographics
NPI:1649226705
Name:BLAIR, MARK A (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:BLAIR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 650886
Mailing Address - Street 2:DEPT. 41958
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265
Mailing Address - Country:US
Mailing Address - Phone:805-919-0094
Mailing Address - Fax:480-222-0269
Practice Address - Street 1:3811 E BELL RD STE 309
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2160
Practice Address - Country:US
Practice Address - Phone:602-971-0950
Practice Address - Fax:602-992-4971
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ32353207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00191312OtherRAIL ROAD MEDICARE
AZ32353OtherARIZONA LICENSE
AZP00191312OtherRAIL ROAD MEDICARE
AZI03602Medicare UPIN
AZ79349Medicare PIN