Healthcare Provider Details

I. General information

NPI: 1447235411
Provider Name (Legal Business Name): UROLOGY ASSOC. OF N.E. FLORIDA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 04/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 VILLAGE WAY
ORANGE PARK FL
32073-5263
US

IV. Provider business mailing address

1715 VILLAGE WAY
ORANGE PARK FL
32073-5263
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberME0023670
License Number StateFL

VIII. Authorized Official

Name: DR. MARC H. BLASSER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 904-264-8418