Provider Demographics
NPI:1407870579
Name:BLANK, KAREN (MD)
Entity Type:Individual
Prefix:DR
First Name:KAREN
Middle Name:
Last Name:BLANK
Suffix:
Gender:F
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:PO BOX 40,000 DEPT 634
Mailing Address - Street 2:HARTFORD HOSPITAL PROFESSIONAL SERVICES
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06151-0634
Mailing Address - Country:US
Mailing Address - Phone:860-545-7602
Mailing Address - Fax:
Practice Address - Street 1:200 RETREAT AVENUE
Practice Address - Street 2:HARTFORD HOSPITAL PSYCHIATRY DEPT
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06102
Practice Address - Country:US
Practice Address - Phone:860-545-0335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0303172084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001303171Medicaid
CT001303171Medicaid
CTB79202Medicare UPIN