Provider Demographics
NPI:1750444766
Name:BLAZE, ALLISON (MD)
Entity Type:Individual
Prefix:DR
First Name:ALLISON
Middle Name:
Last Name:BLAZE
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 1:3291 LOMA VISTA RD
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-3099
Mailing Address - Country:US
Mailing Address - Phone:805-652-6556
Mailing Address - Fax:
Practice Address - Street 1:3291 LOMA VISTA RD
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-3099
Practice Address - Country:US
Practice Address - Phone:805-652-6556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA82136207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH91839Medicare UPIN