Provider Demographics
NPI:1124670088
Name:MOUNTAIN WEST DERM - BLACKHART PLLC
Entity type:Organization
Organization Name:MOUNTAIN WEST DERM - BLACKHART PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRET
Authorized Official - Middle Name:S
Authorized Official - Last Name:BLACKHART
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:775-560-8668
Mailing Address - Street 1:3841 PIPER ST STE T4-020
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4673
Mailing Address - Country:US
Mailing Address - Phone:775-560-8668
Mailing Address - Fax:
Practice Address - Street 1:3841 PIPER ST STE T4-020
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4673
Practice Address - Country:US
Practice Address - Phone:907-646-8500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty