Provider Demographics
NPI:1235417817
Name:BLASICK, JEFFREY S (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:S
Last Name:BLASICK
Suffix:
Gender:M
Credentials:DO
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 16190
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4056
Mailing Address - Country:US
Mailing Address - Phone:254-754-0375
Mailing Address - Fax:254-754-2667
Practice Address - Street 1:5100 FRANKLIN AVE STE C
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710
Practice Address - Country:US
Practice Address - Phone:254-754-0375
Practice Address - Fax:254-754-2667
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-29
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ6735207X00000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXQ6735OtherLICENSE
TXQ6735OtherLICENSE
TXQ6735OtherLICENSE