Provider Demographics
NPI:1457320020
Name:BLOTNICK, CHARLES A (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:BLOTNICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 HUGH FOREST RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28270-3446
Mailing Address - Country:US
Mailing Address - Phone:704-334-2020
Mailing Address - Fax:704-334-6175
Practice Address - Street 1:2015 RANDOLPH RD
Practice Address - Street 2:SUITE 108
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1200
Practice Address - Country:US
Practice Address - Phone:704-334-2020
Practice Address - Fax:704-334-6175
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9901116207W00000X
SC21278207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC212781Medicaid
NC891229KMedicaid
SC212781Medicaid
NC891229KMedicaid
SCG50765-1092Medicare ID - Type Unspecified