Provider Demographics
NPI:1992242655
Name:BLATT, MARK N (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:N
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 1:3175 GRANADA DRIVE
Mailing Address - Street 2:
Mailing Address - City:CAMERON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:95682-8142
Mailing Address - Country:US
Mailing Address - Phone:203-512-3152
Mailing Address - Fax:
Practice Address - Street 1:3175 GRANADA DR
Practice Address - Street 2:
Practice Address - City:CAMERON PARK
Practice Address - State:CA
Practice Address - Zip Code:95682-8142
Practice Address - Country:US
Practice Address - Phone:203-512-3152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-19
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT022835207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT022835OtherCONNECTICUT STATE LICENSE