Provider Demographics
NPI:1467452664
Name:BLAZEK, GEROLD J (MD)
Entity Type:Individual
Prefix:DR
First Name:GEROLD
Middle Name:J
Last Name:BLAZEK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 36840
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87176-6840
Mailing Address - Country:US
Mailing Address - Phone:505-243-7729
Mailing Address - Fax:505-243-4804
Practice Address - Street 1:4401 MASTHEAD ST NE
Practice Address - Street 2:SUITE 120
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4327
Practice Address - Country:US
Practice Address - Phone:505-243-7729
Practice Address - Fax:505-243-4804
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2011-08-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NM86-176207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM37812Medicaid
NM37812Medicaid
NM$$$$$$$$$Medicare PIN