Provider Demographics
NPI:1619129269
Name:JK BLIXT D.O. INC
Entity Type:Organization
Organization Name:JK BLIXT D.O. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLIXT
Authorized Official - Suffix:
Authorized Official - Credentials:DO,FASAM
Authorized Official - Phone:719-896-4794
Mailing Address - Street 1:1715 N WEBER ST STE 260
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-7553
Mailing Address - Country:US
Mailing Address - Phone:719-896-4794
Mailing Address - Fax:719-896-5484
Practice Address - Street 1:1715 N WEBER ST STE 260
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-7553
Practice Address - Country:US
Practice Address - Phone:719-896-4794
Practice Address - Fax:719-896-5484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO38650207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO17204062Medicaid
COC1492Medicare PIN
CO17204062Medicaid