1619093317 NPI number — MRS. DEBORAH FAITH BLITZ OTR

Table of content: MRS. DEBORAH FAITH BLITZ OTR (NPI 1619093317)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619093317 NPI number — MRS. DEBORAH FAITH BLITZ OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLITZ
Provider First Name:
DEBORAH
Provider Middle Name:
FAITH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
YARKON
Provider Other First Name:
DEBORAH
Provider Other Middle Name:
FAITH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1619093317
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2674 HEWLETT LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLMORE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11710-4435
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
917-613-2003
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2674 HEWLETT LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLMORE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11710-4435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
917-613-2003
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/22/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225XP0200X , with the licence number:  10584-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)