Provider Demographics
NPI:1396150140
Name:BLAU, ELLIOT (MD)
Entity type:Individual
Prefix:
First Name:ELLIOT
Middle Name:
Last Name:BLAU
Suffix:
Gender:M
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:PO BOX 26067
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84126-0067
Mailing Address - Country:US
Mailing Address - Phone:239-624-0400
Mailing Address - Fax:239-624-0401
Practice Address - Street 1:311 9TH ST N STE 200
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5887
Practice Address - Country:US
Practice Address - Phone:239-624-1160
Practice Address - Fax:239-624-1161
Is Sole Proprietor?:No
Enumeration Date:2014-06-30
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN20137390200000X
WAML60569414390200000X
FLME147159208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ3W7EOtherBCBS
FL108118800Medicaid