Provider Demographics
NPI:1992778864
Name:BLICKER, ILENA JOYCE (MD)
Entity type:Individual
Prefix:DR
First Name:ILENA
Middle Name:JOYCE
Last Name:BLICKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 ARDEN AVE
Mailing Address - Street 2:SUITE 540
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-1130
Mailing Address - Country:US
Mailing Address - Phone:818-240-1677
Mailing Address - Fax:818-240-0147
Practice Address - Street 1:435 ARDEN AVE
Practice Address - Street 2:SUITE 540
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-1130
Practice Address - Country:US
Practice Address - Phone:818-240-1677
Practice Address - Fax:818-240-0147
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG194242084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G194240Medicaid
CAG19424Medicare ID - Type Unspecified
CAA40641Medicare UPIN