Provider Demographics
NPI:1043211626
Name:BLANK, STEPHANIE (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BLANK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 E 34TH ST
Mailing Address - Street 2:4TH FL.
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-4750
Mailing Address - Country:US
Mailing Address - Phone:212-731-5345
Mailing Address - Fax:
Practice Address - Street 1:160 E 34TH ST
Practice Address - Street 2:4TH FL.
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-4750
Practice Address - Country:US
Practice Address - Phone:212-731-5345
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203247207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02194365Medicaid
NY02194365Medicaid
NY482E01Medicare ID - Type Unspecified