Provider Demographics
NPI:1306222534
Name:BLAZEK, MARK D (DPT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:BLAZEK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10 WILLIAM POPE DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29909-7549
Mailing Address - Country:US
Mailing Address - Phone:843-705-9440
Mailing Address - Fax:843-705-9445
Practice Address - Street 1:3250 HARDEN STREET EXT
Practice Address - Street 2:SUITE 100
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6842
Practice Address - Country:US
Practice Address - Phone:803-509-6389
Practice Address - Fax:803-509-6390
Is Sole Proprietor?:No
Enumeration Date:2015-08-11
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC7901225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist