Provider Demographics
NPI:1174505341
Name:KOVAZ, BLAISE M (MD)
Entity Type:Individual
Prefix:DR
First Name:BLAISE
Middle Name:M
Last Name:KOVAZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12730 NEW BRITTANY BLVD STE 602
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-4690
Mailing Address - Country:US
Mailing Address - Phone:239-275-5522
Mailing Address - Fax:239-275-4464
Practice Address - Street 1:9021 PARK ROYAL DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-9617
Practice Address - Country:US
Practice Address - Phone:239-432-5858
Practice Address - Fax:239-482-6297
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME49497207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL371204400Medicaid
FL208742OtherAVMED
FL000011209MOtherHUMANA
FL15892OtherSTAYWELL
FL09415OtherBC/BS OF FLORIDA
FL208742OtherAVMED
FL09415OtherBC/BS OF FLORIDA