Provider Demographics
NPI:1710988282
Name:BLAD, DENISE E (MD)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:E
Last Name:BLAD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:326 N SAWYER RD
Practice Address - Street 2:
Practice Address - City:KENDALLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46755-2573
Practice Address - Country:US
Practice Address - Phone:260-349-9166
Practice Address - Fax:260-349-9175
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052983A207Q00000X
OH35084375207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2478279Medicaid
IN200187450Medicaid
IN264430FMedicare PIN
OHBL4133141Medicare PIN
IN144020LMedicare PIN
OH2478279Medicaid