Provider Demographics
NPI:1225104888
Name:BLASE, JOHN SCOTT (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:SCOTT
Last Name:BLASE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9250 FM 78
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-2903
Mailing Address - Country:US
Mailing Address - Phone:210-659-1223
Mailing Address - Fax:210-659-2924
Practice Address - Street 1:9250 FM 78
Practice Address - Street 2:
Practice Address - City:CONVERSE
Practice Address - State:TX
Practice Address - Zip Code:78109-2903
Practice Address - Country:US
Practice Address - Phone:210-659-1223
Practice Address - Fax:210-659-2924
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2335TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00E75AOtherMEDICARE PTAN
TX0933889-01Medicaid
TX909816OtherAETNA MED.
TX742006921OtherTRICARE
TX0214780001Medicare NSC
TX742006921OtherTRICARE
TXB26369Medicare UPIN