Provider Demographics
NPI:1679730915
Name:BLAZINA, STACEY (DO)
Entity type:Individual
Prefix:DR
First Name:STACEY
Middle Name:
Last Name:BLAZINA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1903 BETHEL RD
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-5729
Mailing Address - Country:US
Mailing Address - Phone:570-367-9236
Mailing Address - Fax:
Practice Address - Street 1:525 VERDAE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-4021
Practice Address - Country:US
Practice Address - Phone:864-272-0388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC87900208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics