Provider Demographics
NPI:1487631024
Name:BLATTSTEIN, JESSE PETER (OD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:PETER
Last Name:BLATTSTEIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 ARLINGTON DR
Mailing Address - Street 2:
Mailing Address - City:HARRIMAN
Mailing Address - State:NY
Mailing Address - Zip Code:10926-3810
Mailing Address - Country:US
Mailing Address - Phone:845-238-3441
Mailing Address - Fax:
Practice Address - Street 1:371 STATE ROUTE 17M
Practice Address - Street 2:SUITE 3
Practice Address - City:MONROE
Practice Address - State:NY
Practice Address - Zip Code:10950-3434
Practice Address - Country:US
Practice Address - Phone:845-782-3937
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT005307152W00000X, 152WC0802X, 152WP0200X, 152WS0006X
NYV152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Not Answered152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Not Answered152WS0006XEye and Vision Services ProvidersOptometristSports Vision
Not Answered152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01569846Medicaid
NY40834Medicare UPIN
NY01569846Medicaid