Provider Demographics
NPI:1619064490
Name:BLATT, SUSAN M (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:M
Last Name:BLATT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:185 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-2102
Mailing Address - Country:US
Mailing Address - Phone:315-798-5080
Mailing Address - Fax:315-798-5022
Practice Address - Street 1:406 ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-2306
Practice Address - Country:US
Practice Address - Phone:315-798-5747
Practice Address - Fax:315-798-1057
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY127636208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY53857CMedicare PIN