Provider Demographics
NPI:1568987014
Name:EMERSON, BLAZE D (DO)
Entity Type:Individual
Prefix:
First Name:BLAZE
Middle Name:D
Last Name:EMERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7710 S US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-2320
Mailing Address - Country:US
Mailing Address - Phone:772-335-5300
Mailing Address - Fax:772-200-2131
Practice Address - Street 1:7710 S US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-2320
Practice Address - Country:US
Practice Address - Phone:772-335-5300
Practice Address - Fax:772-200-2131
Is Sole Proprietor?:No
Enumeration Date:2017-08-06
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS19620207XS0117X
390200000X
AZ009496207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program