Basic Information
| Provider Information | |||||||||
| NPI: | 1962499673 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLOTTER | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | WALLENTINE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2245 N 400 E | ||||||||
| Address2: | STE 301 | ||||||||
| City: | NORTH LOGAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843411892 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357537880 | ||||||||
| FaxNumber: | 4357535845 | ||||||||
| Practice Location | |||||||||
| Address1: | 2245 N 400 E | ||||||||
| Address2: | STE 301 | ||||||||
| City: | NORTH LOGAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843411892 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357537880 | ||||||||
| FaxNumber: | 4357535845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2005 | ||||||||
| LastUpdateDate: | 06/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YX0007X | 3082587-1205 | UT | Y | Allopathic & Osteopathic Physicians | Otolaryngology | Plastic Surgery within the Head & Neck |
ID Information
| ID | Type | State | Issuer | Description | M-8784 | 01 | ID | IDAHO STATE LICENSE | OTHER | 87037196400 | 05 | UT | MEDICAID | BB5162716 | 01 | UT | DEA | OTHER |