Provider Demographics
NPI:1811948847
Name:KORNBLUTH, STEPHEN S (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:S
Last Name:KORNBLUTH
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 1:71 ALLEN STREET
Mailing Address - Street 2:SUITE 403
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4570
Mailing Address - Country:US
Mailing Address - Phone:802-772-4414
Mailing Address - Fax:802-772-7973
Practice Address - Street 1:275 ROUTE 30 N
Practice Address - Street 2:
Practice Address - City:BOMOSEEN
Practice Address - State:VT
Practice Address - Zip Code:05732-9647
Practice Address - Country:US
Practice Address - Phone:802-468-5641
Practice Address - Fax:802-468-2923
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY153606207Q00000X
VT0420011399207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTP00479978OtherRR MEDICARE
VT1013905Medicaid
NY00773271Medicaid
VTP00479978OtherRR MEDICARE
VT000193601Medicare PIN