Healthcare Provider Details

I. General information

NPI: 1437245875
Provider Name (Legal Business Name): MARC HEPNER BLASSER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 VILLAGE WAY
ORANGE PARK FL
32073
US

IV. Provider business mailing address

1715 VILLAGE WAY
ORANGE PARK FL
32073
US

V. Phone/Fax

Practice location:
  • Phone: 904-264-8418
  • Fax: 904-264-9692
Mailing address:
  • Phone: 904-264-8418
  • Fax: 904-264-9692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberME0059868
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: