Healthcare Provider Details

I. General information

NPI: 1437194354
Provider Name (Legal Business Name): DANIEL R. BLIZZARD DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 CAUSEWAY DR STE 3
OCEAN ISLE BEACH NC
28469-7581
US

IV. Provider business mailing address

120 CAUSEWAY DR STE 3
OCEAN ISLE BEACH NC
28469-7581
US

V. Phone/Fax

Practice location:
  • Phone: 910-575-5004
  • Fax: 855-575-0700
Mailing address:
  • Phone: 910-575-5004
  • Fax: 855-575-0700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2007-01189
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: