Provider Demographics
NPI:1992708655
Name:BLACKHART, BRET S (MD)
Entity type:Individual
Prefix:
First Name:BRET
Middle Name:S
Last Name:BLACKHART
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BRET
Other - Middle Name:S
Other - Last Name:BLACKHART
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:640 W MOANA LN
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-4903
Mailing Address - Country:US
Mailing Address - Phone:775-336-3624
Mailing Address - Fax:775-888-8067
Practice Address - Street 1:640 W MOANA LN
Practice Address - Street 2:STE 2
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-4857
Practice Address - Country:US
Practice Address - Phone:775-324-0699
Practice Address - Fax:775-888-8067
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7747207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVF16608Medicare UPIN
NVWQBGC03Medicare ID - Type Unspecified