Provider Demographics
NPI:1902963457
Name:MARK G. BLASBALG OD INC
Entity Type:Organization
Organization Name:MARK G. BLASBALG OD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:G
Authorized Official - Last Name:BLASBALG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:401-823-8200
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9009739Medicaid
RI419009739Medicare ID - Type Unspecified
RIT53629Medicare UPIN
RI1312470001Medicare NSC