Healthcare Provider Details

I. General information

NPI: 1093718272
Provider Name (Legal Business Name): DAVID J BLAZER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 08/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 HIGHWAY 70 E
DICKSON TN
37055-2080
US

IV. Provider business mailing address

127 CRESTVIEW PARK DR
DICKSON TN
37055-2855
US

V. Phone/Fax

Practice location:
  • Phone: 615-441-4450
  • Fax: 615-446-1357
Mailing address:
  • Phone: 615-446-5121
  • Fax: 615-446-1357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD26023
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberMD26023
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: