Provider Demographics
NPI:1821087537
Name:GOLDBLATT, MARK ROBERT (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ROBERT
Last Name:GOLDBLATT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 603443
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3443
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 CHOCTAW ST
Practice Address - Street 2:SUITE A
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28801-4513
Practice Address - Country:US
Practice Address - Phone:828-255-7733
Practice Address - Fax:828-225-5207
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC737207R00000X, 208000000X
NC2010-00831207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ951279Medicaid
NM72032782Medicaid
CO00426369Medicaid
CO00426369Medicaid
AZ951279Medicaid
8HE087Medicare PIN