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 1:1106 REYNOLDS ST STE 100
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-4376
Practice Address - Country:US
Practice Address - Phone:704-289-5443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-12
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC390200000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program