Provider Demographics
NPI:1073034609
Name:BLAVAT, JAMIE L (OD)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:L
Last Name:BLAVAT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1808 W BELTLINE HWY
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-2334
Mailing Address - Country:US
Mailing Address - Phone:608-250-1497
Mailing Address - Fax:608-250-1384
Practice Address - Street 1:1513 PARK AVE FL 1
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:WI
Practice Address - Zip Code:53925-1793
Practice Address - Country:US
Practice Address - Phone:920-623-2431
Practice Address - Fax:920-623-3656
Is Sole Proprietor?:No
Enumeration Date:2017-07-05
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3475-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1073034609Medicaid