Provider Demographics
NPI:1326199316
Name:KORNBLUTH, IAN (MPT)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:KORNBLUTH
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21416 N 38TH PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-4969
Mailing Address - Country:US
Mailing Address - Phone:609-651-3155
Mailing Address - Fax:609-644-3817
Practice Address - Street 1:800 BUNN DR STE 102
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08540-1968
Practice Address - Country:US
Practice Address - Phone:800-455-8982
Practice Address - Fax:609-644-3817
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2019-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00849800225100000X
AZLPT-013539225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist