Provider Demographics
NPI:1740646181
Name:BLINNIKOVA, KSENIA NIKOLAYEVNA (MD)
Entity type:Individual
Prefix:
First Name:KSENIA
Middle Name:NIKOLAYEVNA
Last Name:BLINNIKOVA
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 1:50 STANIFORD ST FL 9
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2506
Mailing Address - Country:US
Mailing Address - Phone:614-724-6610
Mailing Address - Fax:
Practice Address - Street 1:50 STANIFORD ST FL 9
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2506
Practice Address - Country:US
Practice Address - Phone:612-724-6610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-14
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL37486207QB0002X
MA1013709207QB0002X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity Medicine