Provider Demographics
NPI:1700893138
Name:BLASE, MARVIN (MD)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:
Last Name:BLASE
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:POB 720440
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30358-2440
Mailing Address - Country:US
Mailing Address - Phone:770-671-1312
Mailing Address - Fax:770-671-0005
Practice Address - Street 1:990 RIVERSIDE TRUCE
Practice Address - Street 2:
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30328-1640
Practice Address - Country:US
Practice Address - Phone:770-671-1312
Practice Address - Fax:770-671-0005
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA167782084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
D39431Medicare UPIN