Provider Demographics
NPI:1861498131
Name:BLATT, MARC BENJAMIN (DO)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:BENJAMIN
Last Name:BLATT
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 1:8773 PERIMETER PARK CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-1165
Mailing Address - Country:US
Mailing Address - Phone:904-493-3390
Mailing Address - Fax:904-493-3395
Practice Address - Street 1:8773 PERIMETER PARK CT
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1165
Practice Address - Country:US
Practice Address - Phone:904-493-3390
Practice Address - Fax:904-493-3395
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7862207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2610299-00OtherMEDICAID - GROUP
FL195802OtherWELLCARE
FL110220691OtherRR MEDICARE
FL03058ZOtherMEDICARE - INDIVIDUAL
FL03058OtherFLORIDA BLUE
FL2615959-00OtherMEDICAID - INDIVIDUAL
FL278741OtherAVMED
FL45681OtherMEDICARE - GROUP
FL278741OtherAVMED