Healthcare Provider Details

I. General information

NPI: 1801653373
Provider Name (Legal Business Name): MARTINA BLAZEVIC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2024
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3595 OLENTANGY RIVER RD
COLUMBUS OH
43214-3440
US

IV. Provider business mailing address

18501 HILLIARD BLVD APT 110
ROCKY RIVER OH
44116-2934
US

V. Phone/Fax

Practice location:
  • Phone: 614-566-5456
  • Fax:
Mailing address:
  • Phone: 440-454-5469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number57.258346
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: