Provider Demographics
NPI:1902998776
Name:BLAHA, GREGORY R (MD, PHD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:R
Last Name:BLAHA
Suffix:
Gender:M
Credentials:MD, PHD
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Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:ONE ESSEX CENTER DRIVE
Mailing Address - Street 2:LAHEY CLINIC
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-2901
Mailing Address - Country:US
Mailing Address - Phone:978-538-4400
Mailing Address - Fax:978-538-4724
Practice Address - Street 1:ONE ESSEX CENTER DRIVE
Practice Address - Street 2:LAHEY CLINIC
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-2901
Practice Address - Country:US
Practice Address - Phone:978-538-4400
Practice Address - Fax:978-538-4724
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2019-05-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA221050207WX0107X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110037878AMedicaid
MA110037878AMedicaid
MAA36838Medicare PIN
MAI07922Medicare UPIN