Basic Information
| Provider Information | |||||||||
| NPI: | 1447764741 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNTAIN WEST DERM - BLACKHART PLLC | ||||||||
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| OtherOrganizationName: | BEND DERMATOLOGY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 640 W MOANA LN | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895094903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7753240699 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2747 NE CONNERS AVE | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977018738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413825712 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2017 | ||||||||
| LastUpdateDate: | 11/22/2017 | ||||||||
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| AuthorizedOfficialLastName: | BLACKHART | ||||||||
| AuthorizedOfficialFirstName: | BRET | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 7753363624 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.