Provider Demographics
NPI:1396833588
Name:BLAISE, MARIE-NIRVA (MD)
Entity Type:Individual
Prefix:
First Name:MARIE-NIRVA
Middle Name:
Last Name:BLAISE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:653 LAWRENCE ST
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-4615
Mailing Address - Country:US
Mailing Address - Phone:516-561-1318
Mailing Address - Fax:718-401-2888
Practice Address - Street 1:760 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-3049
Practice Address - Country:US
Practice Address - Phone:718-518-5550
Practice Address - Fax:718-518-5111
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207405207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02809763Medicaid
NY207405OtherNYS LICENSE
NY02809763Medicaid