Provider Demographics
NPI:1649274127
Name:BLOCKER, WAYNE S (MD)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:S
Last Name:BLOCKER
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 1:407 N PARSONS AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33510-4537
Mailing Address - Country:US
Mailing Address - Phone:813-681-9048
Mailing Address - Fax:813-653-0088
Practice Address - Street 1:407 N PARSONS AVE
Practice Address - Street 2:STE 101
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33510-4537
Practice Address - Country:US
Practice Address - Phone:813-681-9048
Practice Address - Fax:813-653-0088
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 26545207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL09025ZOtherMEDICARE LEGACY NUMBER
FL10D0861661OtherCLIA
FL0599810800Medicaid
FL160002545OtherRAILROAD MEDICARE #
FL4198947OtherAETNA PROVIDER #
FL592413232OtherCOMMERCIAL ID#
FL09025OtherBCBS ID#
FL103483OtherAVMED ID#
FL592413232OtherTRICARE ID#
FL01456OtherWELLCARE ID#
FLD52004Medicare UPIN