Basic Information
| Provider Information | |||||||||
| NPI: | 1073034609 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAVAT | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1808 W BELTLINE HWY | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537132334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082501497 | ||||||||
| FaxNumber: | 6082501384 | ||||||||
| Practice Location | |||||||||
| Address1: | 1513 PARK AVE FL 1 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539251793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206232431 | ||||||||
| FaxNumber: | 9206233656 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2017 | ||||||||
| LastUpdateDate: | 12/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 3475-35 | WI | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1073034609 | 05 | WI | MEDICAID |