Provider Demographics
NPI:1366554420
Name:BLASBALG, MARK G (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:G
Last Name:BLASBALG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1193 TIOGUE AVE
Mailing Address - Street 2:
Mailing Address - City:COVENTRY
Mailing Address - State:RI
Mailing Address - Zip Code:02816-6122
Mailing Address - Country:US
Mailing Address - Phone:401-823-8200
Mailing Address - Fax:401-826-8708
Practice Address - Street 1:1193 TIOGUE AVE
Practice Address - Street 2:
Practice Address - City:COVENTRY
Practice Address - State:RI
Practice Address - Zip Code:02816-6122
Practice Address - Country:US
Practice Address - Phone:401-823-8200
Practice Address - Fax:401-826-8708
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIODTG00489152W00000X
MA2777152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9009739Medicaid
RIT53629Medicare UPIN