Provider Demographics
NPI:1235417817
Name:BLASICK, JEFFREY S (DO)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:S
Last Name:BLASICK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 16190
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4056
Mailing Address - Country:US
Mailing Address - Phone:254-754-0375
Mailing Address - Fax:254-754-2667
Practice Address - Street 1:7005 WOODWAY DR STE 101
Practice Address - Street 2:
Practice Address - City:WOODWAY
Practice Address - State:TX
Practice Address - Zip Code:76712-6160
Practice Address - Country:US
Practice Address - Phone:254-224-8062
Practice Address - Fax:254-224-6385
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-29
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXQ6735207X00000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXQ6735OtherLICENSE
TXQ6735OtherLICENSE
TXQ6735OtherLICENSE