Provider Demographics
NPI:1306912019
Name:GOLDBLATT, BERNARD JACOB (MD)
Entity type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:JACOB
Last Name:GOLDBLATT
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 1:1870 EAST 19 STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11598
Mailing Address - Country:US
Mailing Address - Phone:718-232-7877
Mailing Address - Fax:718-232-4031
Practice Address - Street 1:1870 EAST 19 STREET
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11598
Practice Address - Country:US
Practice Address - Phone:718-232-7877
Practice Address - Fax:718-232-4031
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY138482207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00808159Medicaid
138482OtherLICENSE
138482OtherLICENSE
67A141Medicare ID - Type Unspecified