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 1:1348 N JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:46750-1850
Mailing Address - Country:US
Mailing Address - Phone:574-855-0139
Mailing Address - Fax:
Practice Address - Street 1:2880 NORTHPARK AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:IN
Practice Address - Zip Code:46750-9700
Practice Address - Country:US
Practice Address - Phone:260-356-6422
Practice Address - Fax:260-356-6423
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-19
Last Update Date:2025-07-09
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