Individual
MR. DOUGLAS ALAN BLAZER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
3475 S ALPINE RD, ROCKFORD, IL 61109-2604
(815) 874-8000
Mailing address
3475 S ALPINE RD, ROCKFORD, IL 61109-2604
(815) 874-8000
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
085004130
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
085004130
STATE MEDICAL LICENSE
IL
Enumeration date
10/13/2011
Last updated
10/13/2011
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