Healthcare Provider Details

I. General information

NPI: 1366018848
Provider Name (Legal Business Name): MOUNTAIN WEST DERM - BLACKHART PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2021
Last Update Date: 06/14/2021
Certification Date: 06/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4513 WILLIAMS DR
GEORGETOWN TX
78633-1302
US

IV. Provider business mailing address

4513 WILLIAMS DR
GEORGETOWN TX
78633-1302
US

V. Phone/Fax

Practice location:
  • Phone: 512-930-3909
  • Fax: 512-240-5469
Mailing address:
  • Phone: 512-763-3803
  • Fax: 512-240-5469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: BRET S BLACKHART
Title or Position: PRESIDENT
Credential: MD
Phone: 775-336-3624