Provider Demographics
NPI:1477011070
Name:BLATNY, JOHN VIKTOR (DPT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:VIKTOR
Last Name:BLATNY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 MEDIA LN
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2811
Mailing Address - Country:US
Mailing Address - Phone:631-434-5397
Mailing Address - Fax:
Practice Address - Street 1:5958 ROUTE 25A
Practice Address - Street 2:
Practice Address - City:WADING RIVER
Practice Address - State:NY
Practice Address - Zip Code:11792-2001
Practice Address - Country:US
Practice Address - Phone:631-929-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044161225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist