Provider Demographics
NPI:1578542932
Name:BLAZEK, BRIDGETTE A (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIDGETTE
Middle Name:A
Last Name:BLAZEK
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 1:5605 W EUGIE AVE STE 111
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85304-1273
Mailing Address - Country:US
Mailing Address - Phone:480-756-0000
Mailing Address - Fax:855-636-8770
Practice Address - Street 1:5605 W EUGIE AVE STE 111
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-1273
Practice Address - Country:US
Practice Address - Phone:480-756-6000
Practice Address - Fax:855-636-8770
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ58068207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ554326Medicaid
ILCA5143OtherMEDICARE RAILROAD
IL31602433OtherBC BS PROVIDER NUMBER
ILI38364Medicare UPIN