Provider Demographics
NPI:1104997923
Name:BLEFELD, MICHAEL E (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:BLEFELD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:495 GOLD STAR HWY
Mailing Address - Street 2:SUITE 120
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-6228
Mailing Address - Country:US
Mailing Address - Phone:860-449-8882
Mailing Address - Fax:860-449-9195
Practice Address - Street 1:495 GOLD STAR HWY
Practice Address - Street 2:SUITE 120
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-6228
Practice Address - Country:US
Practice Address - Phone:860-449-8882
Practice Address - Fax:860-449-9195
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT22070208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
031502OtherHEALTH NET
1416771-005OtherCIGNA
010022070CT01OtherBLUE CROSS BLUE SHIELD
4205040OtherAETNA
620293OtherCONNECTICARE
CT001220706Medicaid
NLP064OtherOXFORD
OTH000Medicare UPIN