Provider Demographics
NPI:1083810485
Name:BLAZER, MARIE MANTINI (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:MANTINI
Last Name:BLAZER
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17428 DEER RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:STRONGSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44136-7258
Mailing Address - Country:US
Mailing Address - Phone:440-887-9761
Mailing Address - Fax:
Practice Address - Street 1:7000 EUCLID AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103-4014
Practice Address - Country:US
Practice Address - Phone:216-231-5612
Practice Address - Fax:216-721-5534
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36.003426213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCH5179OtherRR MEDICARE GROUP
OHP00435157OtherRR MEDICARE CFAC
OHCI 5538OtherRR MEDICARE GROUP BFAC
OH2787140Medicaid
OHCH5179OtherRR MEDICARE GROUP
OH1131510004Medicare NSC
OH9247011Medicare PIN
OHP00435157OtherRR MEDICARE CFAC
OH4310000001Medicare NSC
OH4216231Medicare PIN