Provider Demographics
NPI:1033654009
Name:MARK BLATT ASSOCIATES, INC
Entity Type:Organization
Organization Name:MARK BLATT ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BLATT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-512-3152
Mailing Address - Street 1:3175 GRANADA DR
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-30
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT022835261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care