Provider Demographics
NPI:1194728048
Name:KORNBLATT, NORMAN I (DPM)
Entity type:Individual
Prefix:
First Name:NORMAN
Middle Name:I
Last Name:KORNBLATT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3666 HIGHWAY 5
Mailing Address - Street 2:STE 101
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-6940
Mailing Address - Country:US
Mailing Address - Phone:770-942-3668
Mailing Address - Fax:770-920-9675
Practice Address - Street 1:3666 HIGHWAY 5
Practice Address - Street 2:STE 101
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-6940
Practice Address - Country:US
Practice Address - Phone:770-942-3668
Practice Address - Fax:770-920-9675
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA553213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000344957AMedicaid
GAT97696Medicare UPIN
GA6094380001Medicare NSC