=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962499673
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES WALLENTINE BLOTTER M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2005
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2245 N 400 E STE 301
-----------------------------------------------------
City | NORTH LOGAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84341-1892
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-753-7880
-----------------------------------------------------
Fax | 435-753-5845
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2245 N 400 E STE 301
-----------------------------------------------------
City | NORTH LOGAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84341-1892
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-753-7880
-----------------------------------------------------
Fax | 435-753-5845
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207YX0007X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery within the Head & Neck (Otolaryngology) Physician
-----------------------------------------------------
License Number | 3082587-1205
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------