Provider Demographics
NPI:1255530838
Name:BLATT, REBECCA JEAN
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:JEAN
Last Name:BLATT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:J
Other - Last Name:BLATT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-5362
Mailing Address - Fax:505-923-5362
Practice Address - Street 1:9191 GRANT ST.
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80229-8812
Practice Address - Country:US
Practice Address - Phone:303-450-4482
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT48616207P00000X
NMMD2018-0017207P00000X
CODR.0049804207P00000X, 2083X0100X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO81654278Medicaid
CO81654278Medicaid