Danice Blaise, MD,MBA
Individual provider Active NPI General Practice Physician · Lake Wales, FL
NPI 1255829966 · NPPES record last updated Dec 7, 2024
Key facts
- NPI
- 1255829966
- Entity type
- Individual (NPI type 1)
- Primary specialty
- General Practice Physician 208D00000X
- License
- ACN1418 (FL)
- Practice address
- 684 State Road 60 W
Lake Wales, FL 33853-4419 - Phone
- (863) 949-4868
- Fax
- (863) 223-8549
- NPI assigned
- Apr 27, 2018
- Sex
- Male
- Sole proprietor
- Yes
Organizations & group practices 3
Medicare Care Compare profile
- Specialty
- General Practice
- Education
- Other, 2017
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
Practice addresses (Care Compare)
571 Ave K SE
Winter Haven, FL 33880-4215
Phone (407) 440-0708
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in FL
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20220502000035 | FL | Practitioner - General Practice | 1355738899 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Master of Business Administration, Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 25173 | NH | MD | Internal Medicine Physician |
| CV2000213 | IN | MD | Physician Assistant |
| 2019045102 | MO | MD | Physician Assistant |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Medical Home Alliance LLC | Internal Medicine | Current |
Accepting new patients |
| Medical Home Alliance LLC | Past | Accepting new patients |
Locations
684 State Road 60 W
Lake Wales, FL 33853
Phone (863) 949-4668
6675 Westwood Blvd
Ste 475
Orlando, FL 32821
Phone (407) 845-0384
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Physician | 208D00000X | ACN1418 | FL | Yes |
| Internal Medicine Physician | 207R00000X | 25173 | NH | |
| Physician Assistant | 363A00000X | 2019045102 | MO | |
| Physician Assistant | 363A00000X | CV2000213 | IN | |
| Student in an Organized Health Care Education/Training Program | 390200000X |
Addresses
Primary practice location
684 State Road 60 W
Lake Wales, FL 33853-4419
Mailing address
6675 Westwood Blvd Ste 475
Orlando, FL 32821-6027
Phone (407) 845-0330
Other practice location 1
571 Avenue K SE
Winter Haven, FL 33880-4215
Phone (407) 440-0708
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 115752400 | Medicaid | FL |
Other providers in Lake Wales, FL
- Stephanie Ann Benton
- Jeffrey Berdahl
- Julia Hunt Berkau
- Best Value Healthcare
- Misty Bittner
- Thomas Martin Bonds I
- Brain Spine and Sleep Institute LLC
- Colette Braunstein
- Roy Z Braunstein
- Breuer Health of Lake Wales LLC
All providers in Lake Wales, FL · General Practice Physician in Florida
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 7, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.