Provider Demographics
NPI:1750102083
Name:BLICKENSDERFER, ERIC ROBERT
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:ROBERT
Last Name:BLICKENSDERFER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9373 BENCHMARK DR APT F
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-4209
Mailing Address - Country:US
Mailing Address - Phone:574-855-0139
Mailing Address - Fax:
Practice Address - Street 1:1160 W MICHIGAN ST STE 100
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5209
Practice Address - Country:US
Practice Address - Phone:574-855-0139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-19
Last Update Date:2024-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program