Basic Information
| Provider Information | |||||||||
| NPI: | 1669868493 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLATTNER | ||||||||
| FirstName: | COLLIN | ||||||||
| MiddleName: | MATTHEW | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1793 13TH ST SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973022541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033628385 | ||||||||
| FaxNumber: | 5033628435 | ||||||||
| Practice Location | |||||||||
| Address1: | 1793 13TH ST SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973022541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033628385 | ||||||||
| FaxNumber: | 5033628435 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2015 | ||||||||
| LastUpdateDate: | 05/15/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | PG172025 | OR | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 500753179 | 05 | OR | MEDICAID |