Provider Demographics
NPI:1144215922
Name:KORNBLATT, MARTIN (OD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:
Last Name:KORNBLATT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4202 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-3822
Mailing Address - Country:US
Mailing Address - Phone:718-539-5888
Mailing Address - Fax:718-463-2207
Practice Address - Street 1:4202 MAIN ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-3822
Practice Address - Country:US
Practice Address - Phone:718-539-5888
Practice Address - Fax:718-463-2207
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV004300152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00822977Medicaid
T32219Medicare UPIN
99824Medicare ID - Type Unspecified