Basic Information
| Provider Information | |||||||||
| NPI: | 1295761286 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAZE | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7800 W OAKLAND PARK BLVD | ||||||||
| Address2: | SUITE E-214 | ||||||||
| City: | SUNRISE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333516741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543186590 | ||||||||
| FaxNumber: | 9543186604 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 SW 129TH AVENUE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330271778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544334200 | ||||||||
| FaxNumber: | 9544337710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 04/25/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | OS001666 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 251372200 | 05 | FL | MEDICAID |