Provider Demographics
NPI:1699872705
Name:BLEZA, DAVID ARNOLD (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ARNOLD
Last Name:BLEZA
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:PO BOX 1554
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46308-1554
Mailing Address - Country:US
Mailing Address - Phone:219-736-6850
Mailing Address - Fax:219-736-6855
Practice Address - Street 1:9150 E 109TH AVE
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-7687
Practice Address - Country:US
Practice Address - Phone:219-779-9721
Practice Address - Fax:219-779-9726
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052161A174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200348360Medicaid
INP00981187OtherRAILROAD MEDICARE
IN200348360Medicaid
IN266330AMedicare PIN