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General NPI Number Information
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NPI Number | 1093442121
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Entity Type | Individual
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Provider Name | BLAZE SAMMON OD
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Gender | Male
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Dates
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Enumeration Date | 08/08/2022
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Last Update Date | 10/16/2025
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Provider Practice Location Address
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Address Line | W8159 S US HIGHWAY 2/141 STE 102
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City | IRON MOUNTAIN
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State | MI
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Zip | 49801-9423
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Country | US
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Telephone | 906-779-9164
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Fax | 906-774-5547
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Provider Business Mailing Address
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Address Line | W1974 BEAVER PETE RD
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City | VULCAN
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State | MI
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Zip | 49892-8226
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Country | US
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Telephone | 616-710-9939
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 4901005661
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License Number State | MI
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