Provider Demographics
NPI:1275885220
Name:ABLAZA, MARCELO
Entity Type:Individual
Prefix:
First Name:MARCELO
Middle Name:
Last Name:ABLAZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3952 JOSLIN WAY
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-8489
Mailing Address - Country:US
Mailing Address - Phone:954-257-9545
Mailing Address - Fax:
Practice Address - Street 1:3952 JOSLIN WAY
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-8489
Practice Address - Country:US
Practice Address - Phone:954-257-9545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT26742225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist