Provider Demographics
NPI:1154682565
Name:BLATTER, RICHARD ALAN (DO)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALAN
Last Name:BLATTER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2375 CORONADO ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7407
Mailing Address - Country:US
Mailing Address - Phone:208-552-1234
Mailing Address - Fax:208-524-4540
Practice Address - Street 1:2001 S WOODRUFF AVE STE 4
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6371
Practice Address - Country:US
Practice Address - Phone:208-524-4511
Practice Address - Fax:208-524-4540
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5315055574208800000X
MI5101019997208800000X
MIO-1041208800000X
IDO-1041208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDO-1041OtherIDAHO STATE LICENSE
MI1154682565Medicaid