Provider Demographics
NPI:1902986334
Name:BLAZO, MARIA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIA
Middle Name:
Last Name:BLAZO
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:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:800-994-0371
Mailing Address - Fax:
Practice Address - Street 1:2401 S 31ST ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76508-0001
Practice Address - Country:US
Practice Address - Phone:254-724-6288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6553207Q00000X, 207SG0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0203XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Molecular Genetics
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX122130105Medicaid
TX8L5691Medicare PIN
TX8C2489Medicare PIN
F99538Medicare UPIN
TX8D0941Medicare PIN
TX8J1003Medicare PIN