Provider Demographics
NPI:1558358036
Name:BLATTER, KETT G (OD)
Entity Type:Individual
Prefix:MR
First Name:KETT
Middle Name:G
Last Name:BLATTER
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 1:220 N MCKEMY AVE
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-2654
Mailing Address - Country:US
Mailing Address - Phone:480-961-1865
Mailing Address - Fax:480-961-4605
Practice Address - Street 1:220 N MCKEMY AVE
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-2654
Practice Address - Country:US
Practice Address - Phone:480-961-1865
Practice Address - Fax:480-961-4605
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1237152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ78779Medicare ID - Type UnspecifiedMEDICARE/MEDICAID NUMBER
AZZ163261Medicare PIN
AZU97458Medicare UPIN
AZZ162074Medicare PIN
AZZ162076Medicare PIN