Healthcare Provider Details

I. General information

NPI: 1639517600
Provider Name (Legal Business Name): DOUGLAS BLATY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2013
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 W IRONWOOD DR STE 300
COEUR D ALENE ID
83814-4903
US

IV. Provider business mailing address

850 W IRONWOOD DR STE 300
COEUR D ALENE ID
83814-4903
US

V. Phone/Fax

Practice location:
  • Phone: 208-667-1376
  • Fax: 208-292-0873
Mailing address:
  • Phone: 208-667-1376
  • Fax: 208-292-0873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberO-1231
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: