Provider Demographics
NPI:1932258522
Name:BLATTAU, GWYNETH (MD)
Entity Type:Individual
Prefix:DR
First Name:GWYNETH
Middle Name:
Last Name:BLATTAU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12519 N DIVISION ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99218-1936
Mailing Address - Country:US
Mailing Address - Phone:509-290-6149
Mailing Address - Fax:855-474-9086
Practice Address - Street 1:12519 N DIVISION ST
Practice Address - Street 2:SUITE 6
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99218-1389
Practice Address - Country:US
Practice Address - Phone:509-290-6149
Practice Address - Fax:855-474-9086
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60271577261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD61533501OtherCAREFIRST OF MARYLAND
MD022LD409Medicare ID - Type UnspecifiedMEDICARE #
MD414990400Medicaid
MD827032OtherMAMSI HMO PCP
MD110233667OtherRAILROAD MEDICARE
MD4461101OtherAETNA NON-HMO PCP
DCC0410028OtherCAREFIRST OF DC
MD2148224OtherAETNA HMO PCP
MDH60178Medicare UPIN