Provider Demographics
NPI:1568626257
Name:BLATT, STEPHEN ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:ANDREW
Last Name:BLATT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:900 N SHORE DR
Mailing Address - Street 2:#140
Mailing Address - City:LAKE BLUFF
Mailing Address - State:IL
Mailing Address - Zip Code:60044-2243
Mailing Address - Country:US
Mailing Address - Phone:312-504-3433
Mailing Address - Fax:
Practice Address - Street 1:900 N SHORE DR
Practice Address - Street 2:#140
Practice Address - City:LAKE BLUFF
Practice Address - State:IL
Practice Address - Zip Code:60044-2243
Practice Address - Country:US
Practice Address - Phone:312-504-3433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-11
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036126664207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL789980001Medicare PIN