Provider Demographics
NPI:1093760555
Name:BLAETTLER, KURT (OD)
Entity Type:Individual
Prefix:DR
First Name:KURT
Middle Name:
Last Name:BLAETTLER
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 1986
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29622-1986
Mailing Address - Country:US
Mailing Address - Phone:864-226-6041
Mailing Address - Fax:864-226-1299
Practice Address - Street 1:2808 E. NORTH AVE.
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29625-2300
Practice Address - Country:US
Practice Address - Phone:864-226-6041
Practice Address - Fax:864-226-1299
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC824152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT251563776OtherMEDICARE PTAN
SCD08249Medicaid
SCT251563775OtherMEDICARE PTAN
SCT25156Medicare UPIN
SC0617510001Medicare NSC
SCD08249Medicaid