Provider Demographics
NPI:1164301677
Name:BLAZEK, EVAN
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:BLAZEK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 S GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OH
Mailing Address - Zip Code:45810-1311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:402 W COLLEGE AVE UNIT 2622
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OH
Practice Address - Zip Code:45810-6109
Practice Address - Country:US
Practice Address - Phone:317-474-5402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-28
Last Update Date:2025-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program