Provider Demographics
NPI:1932250297
Name:DR KENNETH BLAZE PA AND ASSOCIATES
Entity type:Organization
Organization Name:DR KENNETH BLAZE PA AND ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-433-4200
Mailing Address - Street 1:1 SW 129TH AVE
Mailing Address - Street 2:SUITE 109
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33027-1761
Mailing Address - Country:US
Mailing Address - Phone:954-433-4200
Mailing Address - Fax:954-433-7710
Practice Address - Street 1:1 SW 129TH AVE
Practice Address - Street 2:SUITE 109
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-1761
Practice Address - Country:US
Practice Address - Phone:954-433-4200
Practice Address - Fax:954-433-7710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty