Provider Demographics
NPI:1992069009
Name:BLICKENDORF, JAMES MATTHEW (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:MATTHEW
Last Name:BLICKENDORF
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 1:1500 N RITTER AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-3027
Mailing Address - Country:US
Mailing Address - Phone:317-355-5322
Mailing Address - Fax:
Practice Address - Street 1:1500 N RITTER AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-3027
Practice Address - Country:US
Practice Address - Phone:317-355-5322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-03
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01075354A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine