Healthcare Provider Details

I. General information

NPI: 1770532988
Provider Name (Legal Business Name): BLAZE SEKOVSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 09/29/2022
Certification Date: 09/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W FORT ST # 111
BOISE ID
83702-4501
US

IV. Provider business mailing address

500 W FORT ST # 111
BOISE ID
83702-4501
US

V. Phone/Fax

Practice location:
  • Phone: 208-422-1325
  • Fax: 208-422-1319
Mailing address:
  • Phone: 208-422-1325
  • Fax: 208-422-1319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number152495-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberM-16757
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: