Provider Demographics
NPI:1992787998
Name:BLATTNER, LARRY MARK (DO)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:MARK
Last Name:BLATTNER
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 56116
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85079
Mailing Address - Country:US
Mailing Address - Phone:480-731-4714
Mailing Address - Fax:480-731-5425
Practice Address - Street 1:2000 WEST BETHANY HOME ROAD
Practice Address - Street 2:PHOENIX BAPTIST HOSPITAL
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015
Practice Address - Country:US
Practice Address - Phone:480-731-4714
Practice Address - Fax:480-731-5425
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZDO2336207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ299059Medicaid
E52279Medicare UPIN
DO2336Medicare ID - Type Unspecified