Provider Demographics
NPI:1194779926
Name:LATRIANO, BLAISE P (MD)
Entity type:Individual
Prefix:
First Name:BLAISE
Middle Name:P
Last Name:LATRIANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 BRASS CASTLE RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07882-4327
Mailing Address - Country:US
Mailing Address - Phone:908-835-1910
Mailing Address - Fax:908-835-1886
Practice Address - Street 1:185 ROSEBERRY ST
Practice Address - Street 2:
Practice Address - City:PHILLIPSBURG
Practice Address - State:NJ
Practice Address - Zip Code:08865-1690
Practice Address - Country:US
Practice Address - Phone:908-859-6779
Practice Address - Fax:908-859-6813
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA71175207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8359202Medicaid
NJ8359202Medicaid
PA065989Medicare PIN
NJ043660Medicare PIN