Provider Demographics
NPI:1386611762
Name:BLONDIN, MATTHEW (OD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:BLONDIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 448
Mailing Address - Street 2:379 PROSPECT STREET SUITE B
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790-0448
Mailing Address - Country:US
Mailing Address - Phone:860-489-2781
Mailing Address - Fax:860-489-9017
Practice Address - Street 1:379 PROSPECT STREET
Practice Address - Street 2:SUITE B
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-0448
Practice Address - Country:US
Practice Address - Phone:860-489-2781
Practice Address - Fax:860-489-9017
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000845152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004024592Medicaid
T22887Medicare UPIN
CT004024592Medicaid