Provider Demographics
NPI:1669868493
Name:BLATTNER, COLLIN MATTHEW (DO)
Entity type:Individual
Prefix:DR
First Name:COLLIN
Middle Name:MATTHEW
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 2430
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-8022
Mailing Address - Country:US
Mailing Address - Phone:541-316-6575
Mailing Address - Fax:541-210-8913
Practice Address - Street 1:1815 E 19TH ST STE B
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3385
Practice Address - Country:US
Practice Address - Phone:541-316-6575
Practice Address - Fax:412-108-9135
Is Sole Proprietor?:No
Enumeration Date:2015-04-08
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO177547207ND0101X
ORPG172025207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500753179Medicaid