Provider Demographics
NPI:1548766835
Name:BLATY, JUSTIN (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:BLATY
Suffix:
Gender:M
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:PO BOX 190930
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0930
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:1075 N CURTIS RD STE 201
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1350
Practice Address - Country:US
Practice Address - Phone:208-302-3300
Practice Address - Fax:208-302-3355
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2024-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI772332080S0012X
WAMD611457272080S0012X
390200000X
IDM-176232080S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080S0012XAllopathic & Osteopathic PhysiciansPediatricsSleep Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1548766835Medicaid