Provider Demographics
NPI:1487624540
Name:BLONDER, BRYAN JAY (DO)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:JAY
Last Name:BLONDER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4911 SAND HILL DR
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479
Mailing Address - Country:US
Mailing Address - Phone:281-634-9600
Mailing Address - Fax:281-634-9601
Practice Address - Street 1:4911 SAND HILL DR
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479
Practice Address - Country:US
Practice Address - Phone:281-634-9600
Practice Address - Fax:281-634-9601
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6990207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G83541Medicare UPIN
TX81608KMedicare PIN