1235212085 NPI number — SCOTT M BLAHNIK O.D.

Table of content: SCOTT M BLAHNIK O.D. (NPI 1235212085)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235212085 NPI number — SCOTT M BLAHNIK O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAHNIK
Provider First Name:
SCOTT
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235212085
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
93 TERRY PARKWAY
Provider Second Line Business Mailing Address:
SUITE 9
Provider Business Mailing Address City Name:
TERRYTOWN
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70056
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-361-4446
Provider Business Mailing Address Fax Number:
504-361-4695

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
93 TERRY PKWY
Provider Second Line Business Practice Location Address:
SUITE 9
Provider Business Practice Location Address City Name:
TERRYTOWN
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70056-5502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-361-4446
Provider Business Practice Location Address Fax Number:
504-361-4695
Provider Enumeration Date:
10/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152WC0802X , with the licence number:  931-158T , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 931158T , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1370851 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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