Provider Demographics
NPI:1659013340
Name:BLAZEK, COOPER (MD)
Entity type:Individual
Prefix:
First Name:COOPER
Middle Name:
Last Name:BLAZEK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5761 CEDERMERE DRIVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106
Mailing Address - Country:US
Mailing Address - Phone:336-688-6012
Mailing Address - Fax:
Practice Address - Street 1:16645 BIRKDALE COMMONS PKWY # 100A
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-5669
Practice Address - Country:US
Practice Address - Phone:170-480-1739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-12
Last Update Date:2025-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2025-01811207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program