Provider Demographics
NPI:1063524361
Name:BLUMENTHAL, GAIL (OD)
Entity type:Individual
Prefix:DR
First Name:GAIL
Middle Name:
Last Name:BLUMENTHAL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-3508
Mailing Address - Country:US
Mailing Address - Phone:201-863-6162
Mailing Address - Fax:201-894-0220
Practice Address - Street 1:17 GRAND AVE
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-3508
Practice Address - Country:US
Practice Address - Phone:201-863-6162
Practice Address - Fax:201-894-0220
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJOA03953152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ521572Medicare ID - Type Unspecified
NJ521572X36Medicare PIN
NJ402329Medicare UPIN