Provider Demographics
NPI:1255829966
Name:BLAISE, DANICE (MD,MBA)
Entity Type:Individual
Prefix:DR
First Name:DANICE
Middle Name:
Last Name:BLAISE
Suffix:
Gender:M
Credentials:MD,MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6675 WESTWOOD BLVD STE 475
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32821-6027
Mailing Address - Country:US
Mailing Address - Phone:407-845-0330
Mailing Address - Fax:888-972-1752
Practice Address - Street 1:684 STATE ROAD 60 W
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4419
Practice Address - Country:US
Practice Address - Phone:863-949-4868
Practice Address - Fax:863-223-8549
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-27
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019045102363A00000X
INCV2000213363A00000X
390200000X
FLACN1418208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL115752400Medicaid