Provider Demographics
NPI:1285611970
Name:BLUMENTAL, GEORGE (MD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:
Last Name:BLUMENTAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 HARRISON AVE
Mailing Address - Street 2:YACC BN-C7
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-4001
Mailing Address - Country:US
Mailing Address - Phone:617-414-5405
Mailing Address - Fax:617-414-6031
Practice Address - Street 1:49 PEARL ST
Practice Address - Street 2:STE DOB-915
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-2817
Practice Address - Country:US
Practice Address - Phone:508-580-1020
Practice Address - Fax:508-583-6232
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA28931207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2077507Medicaid
MA2077507Medicaid
C20161Medicare ID - Type Unspecified