Provider Demographics
NPI:1467591552
Name:BLAIR, CHARLES LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:LEE
Last Name:BLAIR
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 1:836 FARMINGTON AVE STE 217B
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-1545
Mailing Address - Country:US
Mailing Address - Phone:860-523-1451
Mailing Address - Fax:860-523-1437
Practice Address - Street 1:836 FARMINGTON AVE STE 217B
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119-1545
Practice Address - Country:US
Practice Address - Phone:860-523-1451
Practice Address - Fax:860-523-1437
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0247032084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010024703CT02OtherANTHEM ID NUMBER
CT1247030Medicaid
CTD02656Medicare UPIN
CT260000735Medicare ID - Type UnspecifiedPROVIDER NUMBER