Provider Demographics
NPI:1053317248
Name:BLAZEK, MATTHEW C (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:C
Last Name:BLAZEK
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 378
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44871-0378
Mailing Address - Country:US
Mailing Address - Phone:419-609-1112
Mailing Address - Fax:419-609-1123
Practice Address - Street 1:29257 CENTER RIDGE RD
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-5224
Practice Address - Country:US
Practice Address - Phone:440-899-7677
Practice Address - Fax:440-899-7667
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2018-09-18
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
OH48402207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0512850Medicaid
OHBL0528022Medicare ID - Type Unspecified
OH0512850Medicaid