Provider Demographics
NPI:1093337446
Name:KORNBLUM, BENJAMIN J
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:J
Last Name:KORNBLUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 W SENECA ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-4130
Mailing Address - Country:US
Mailing Address - Phone:607-697-0360
Mailing Address - Fax:607-272-0240
Practice Address - Street 1:302 W SENECA ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-4130
Practice Address - Country:US
Practice Address - Phone:607-697-0360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-08
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY346283363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily