Provider Demographics
NPI:1306984034
Name:GLODOWSKI, BLAISE K (DC)
Entity type:Individual
Prefix:DR
First Name:BLAISE
Middle Name:K
Last Name:GLODOWSKI
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 LICCIARDELLO DR
Mailing Address - Street 2:
Mailing Address - City:WOOLWICH TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08085-1819
Mailing Address - Country:US
Mailing Address - Phone:856-241-1585
Mailing Address - Fax:
Practice Address - Street 1:360 E BROAD ST
Practice Address - Street 2:
Practice Address - City:GIBBSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08027-1470
Practice Address - Country:US
Practice Address - Phone:856-423-3899
Practice Address - Fax:856-423-5450
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMCO3280111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2096200Medicaid
NJ481114Medicare ID - Type Unspecified
NJ2096200Medicaid