Basic Information
| Provider Information | |||||||||
| NPI: | 1932250297 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DR KENNETH BLAZE PA AND ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 SW 129TH AVE | ||||||||
| Address2: | SUITE 109 | ||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330271761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544334200 | ||||||||
| FaxNumber: | 9544337710 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 SW 129TH AVE | ||||||||
| Address2: | SUITE 109 | ||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330271761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544334200 | ||||||||
| FaxNumber: | 9544337710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2007 | ||||||||
| LastUpdateDate: | 12/09/2009 | ||||||||
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| AuthorizedOfficialLastName: | GONZALEZ | ||||||||
| AuthorizedOfficialFirstName: | MANUEL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 9544334200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.