Provider Demographics
NPI:1366478158
Name:GOLDBLATT, JEFFREY STUART (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:STUART
Last Name:GOLDBLATT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 HUNTLEY RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:OLD LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06371-1449
Mailing Address - Country:US
Mailing Address - Phone:860-434-4073
Mailing Address - Fax:860-434-4635
Practice Address - Street 1:4 HUNTLEY ROAD
Practice Address - Street 2:SUTIE 1
Practice Address - City:OLD LYME
Practice Address - State:CT
Practice Address - Zip Code:06371
Practice Address - Country:US
Practice Address - Phone:860-434-4073
Practice Address - Fax:860-434-4635
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT016369208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP3645106OtherOXFORD
CT001163690Medicaid
CT2590570OtherCIGNA
CT2V5496OtherHEALTH NET
CT65-1212930OtherTAX ID
CT719901J245OtherCONNECTICARE
CT010016369CT03OtherANTHEM BCBS
CT3444674OtherAETNA
CTB38651Medicare UPIN
CT020001594Medicare ID - Type UnspecifiedMEDICARE