Provider Demographics
NPI:1538106240
Name:BLECKER, DOUGLAS L (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:L
Last Name:BLECKER
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 1:455 TOLL GATE RD
Mailing Address - Street 2:PRC AND CREDENTIALING
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-2759
Mailing Address - Country:US
Mailing Address - Phone:401-273-0641
Mailing Address - Fax:401-273-2919
Practice Address - Street 1:75 SOCKANOSSET CROSS RD STE 100
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-5558
Practice Address - Country:US
Practice Address - Phone:401-736-4500
Practice Address - Fax:401-459-0231
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2025-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD11204207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9025796Medicaid
RIP00044124OtherRAILROAD
RI007056368Medicare PIN