Provider Demographics
NPI:1295704468
Name:ZELAYA, BLAS (MD)
Entity type:Individual
Prefix:
First Name:BLAS
Middle Name:
Last Name:ZELAYA
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 1:1 ILLINI DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61605-2576
Mailing Address - Country:US
Mailing Address - Phone:309-671-8503
Mailing Address - Fax:
Practice Address - Street 1:515 NE GLEN OAK AVE
Practice Address - Street 2:PEDIATRIC NEUROLOGY #308
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3165
Practice Address - Country:US
Practice Address - Phone:309-624-9844
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2080P0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL01BVOtherJOHN DEERE
IL07215036OtherBCBS
IL07215036OtherBCBS
ILIL01BVOtherJOHN DEERE