1659994440 NPI number — DR. GREGG DAVID BLUMBERG DO

Table of content: DR. GREGG DAVID BLUMBERG DO (NPI 1659994440)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659994440 NPI number — DR. GREGG DAVID BLUMBERG DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLUMBERG
Provider First Name:
GREGG
Provider Middle Name:
DAVID
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659994440
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
260 1ST ST APT D14
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINEOLA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11501-2373
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-558-9822
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
NYU LISOM 222 STATION PLAZA NORTH
Provider Second Line Business Practice Location Address:
SUITE 510
Provider Business Practice Location Address City Name:
MINEOLA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11501-3893
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-663-8794
Provider Business Practice Location Address Fax Number:
516-663-8796
Provider Enumeration Date:
05/27/2020

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: 2085R0202X , with the licence number:  1659994440 , 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)





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