Provider Demographics
NPI:1699749804
Name:BLATT, JONATHAN M (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:M
Last Name:BLATT
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 1:6542 SE LAKE RD.
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222
Mailing Address - Country:US
Mailing Address - Phone:503-654-5636
Mailing Address - Fax:503-654-5638
Practice Address - Street 1:6542 SE LAKE RD.
Practice Address - Street 2:SUITE 202
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222
Practice Address - Country:US
Practice Address - Phone:503-654-5636
Practice Address - Fax:503-654-5638
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD16764207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR050038330OtherRR MEDICARE
WA8291734Medicaid
OR009907Medicaid
OR050038330OtherRR MEDICARE
OR00WCJPPD5Medicare ID - Type Unspecified