Provider Demographics
NPI:1376503482
Name:BLAZE, PAUL A (OD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:A
Last Name:BLAZE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:5092 WARNER AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-4030
Mailing Address - Country:US
Mailing Address - Phone:714-846-2897
Mailing Address - Fax:714-846-5778
Practice Address - Street 1:5092 WARNER AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92649-4030
Practice Address - Country:US
Practice Address - Phone:714-846-2897
Practice Address - Fax:714-846-5778
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAFNP 1020152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT70196Medicare UPIN
CAOP7420Medicare PIN