Basic Information
Provider Information | |||||||||
NPI: | 1861498131 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLATT | ||||||||
FirstName: | MARC | ||||||||
MiddleName: | BENJAMIN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8773 PERIMETER PARK CT | ||||||||
Address2: |   | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 322161165 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9044933390 | ||||||||
FaxNumber: | 9044933395 | ||||||||
Practice Location | |||||||||
Address1: | 8773 PERIMETER PARK CT | ||||||||
Address2: |   | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 322161165 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9044933390 | ||||||||
FaxNumber: | 9044933395 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/22/2005 | ||||||||
LastUpdateDate: | 08/04/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | OS7862 | FL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | OS7862 | FL | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 2610299-00 | 01 | FL | MEDICAID - GROUP | OTHER | 195802 | 01 | FL | WELLCARE | OTHER | 110220691 | 01 | FL | RR MEDICARE | OTHER | 03058Z | 01 | FL | MEDICARE - INDIVIDUAL | OTHER | 03058 | 01 | FL | FLORIDA BLUE | OTHER | 2615959-00 | 01 | FL | MEDICAID - INDIVIDUAL | OTHER | 278741 | 01 | FL | AVMED | OTHER | 45681 | 01 | FL | MEDICARE - GROUP | OTHER |