Provider Demographics
NPI:1215019070
Name:JABLONKA, JOHN (PT)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:JABLONKA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 PINE ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1137
Mailing Address - Country:US
Mailing Address - Phone:315-476-3176
Mailing Address - Fax:315-476-0171
Practice Address - Street 1:475 IRVING AVE
Practice Address - Street 2:STE. 094
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1756
Practice Address - Country:US
Practice Address - Phone:315-422-2380
Practice Address - Fax:315-474-7692
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7873174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR55750Medicare UPIN