Provider Demographics
NPI:1053657189
Name:BLAZEK, KELLY KEUNEKE (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:KEUNEKE
Last Name:BLAZEK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6301 ALMEDA RD
Mailing Address - Street 2:APT 615
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 BAYLOR PLZ
Practice Address - Street 2:BCM610
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-3411
Practice Address - Country:US
Practice Address - Phone:832-826-7315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-18
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10042984207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology