Provider Demographics
NPI:1043376676
Name:BLODGETT, WILLIAM RANDOLPH (OD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:RANDOLPH
Last Name:BLODGETT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:500 MILL ST
Mailing Address - Street 2:SUITE A-1
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17821-1015
Mailing Address - Country:US
Mailing Address - Phone:570-275-0901
Mailing Address - Fax:570-275-0901
Practice Address - Street 1:500 MILL ST
Practice Address - Street 2:SUITE A-1
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17821-1015
Practice Address - Country:US
Practice Address - Phone:570-275-0901
Practice Address - Fax:570-275-0901
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2011-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001014152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PABL750828OtherBLUE SHIELD
PA8752Medicare UPIN
PABL750828Medicare ID - Type UnspecifiedMEDICARE