Provider Demographics
NPI:1346439247
Name:MOONEY, BLAISE P (MD)
Entity Type:Individual
Prefix:
First Name:BLAISE
Middle Name:P
Last Name:MOONEY
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12902 USF MAGNOLIA DR
Mailing Address - Street 2:MEDICAL STAFF DERVICES-MCC-FA
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-9416
Mailing Address - Country:US
Mailing Address - Phone:813-745-2710
Mailing Address - Fax:813-745-6855
Practice Address - Street 1:12902 USF MAGNOLIA DR
Practice Address - Street 2:MEDICAL STAFF DERVICES-MCC-FA
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-9416
Practice Address - Country:US
Practice Address - Phone:813-745-2710
Practice Address - Fax:813-745-6855
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME997902085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1457AOtherBLUE CROSS BLUE SHIELD OF FLORIDA
FL001144800Medicaid