Provider Demographics
NPI:1679730907
Name:BLANTON, MATTHEW WEST (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:WEST
Last Name:BLANTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3633 HARDEN RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-3369
Mailing Address - Country:US
Mailing Address - Phone:919-785-0505
Mailing Address - Fax:
Practice Address - Street 1:3633 HARDEN RD
Practice Address - Street 2:SUITE 200
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-3369
Practice Address - Country:US
Practice Address - Phone:919-785-0505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-22
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11011245A208600000X
NC2009-00275208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCA593AMedicare UPIN