Provider Demographics
NPI:1447764741
Name:MOUNTAIN WEST DERM - BLACKHART PLLC
Entity Type:Organization
Organization Name:MOUNTAIN WEST DERM - BLACKHART PLLC
Other - Org Name:BEND DERMATOLOGY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:BRET
Authorized Official - Middle Name:S
Authorized Official - Last Name:BLACKHART
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:775-336-3624
Mailing Address - Street 1:640 W MOANA LN
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-4903
Mailing Address - Country:US
Mailing Address - Phone:775-324-0699
Mailing Address - Fax:
Practice Address - Street 1:2747 NE CONNERS AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-8738
Practice Address - Country:US
Practice Address - Phone:541-382-5712
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-22
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty