Provider Demographics
NPI:1093945404
Name:BLUMBERG, LAURENCE (MD)
Entity Type:Individual
Prefix:
First Name:LAURENCE
Middle Name:
Last Name:BLUMBERG
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 1:424 W END AVE
Mailing Address - Street 2:21J
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-5760
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:424 W END AVE
Practice Address - Street 2:21J
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-5760
Practice Address - Country:US
Practice Address - Phone:212-734-7405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-20
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042521E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine