Provider Demographics
NPI:1750606042
Name:THEDINGER, BLAIR ASHTON
Entity type:Individual
Prefix:DR
First Name:BLAIR
Middle Name:ASHTON
Last Name:THEDINGER
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 1:3515 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64111-2537
Mailing Address - Country:US
Mailing Address - Phone:816-753-5144
Mailing Address - Fax:816-756-1081
Practice Address - Street 1:3515 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-2537
Practice Address - Country:US
Practice Address - Phone:816-753-5144
Practice Address - Fax:816-756-1081
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-30
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-36367207Q00000X
MO2013033410207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine