Provider Demographics
NPI:1336136787
Name:GREENBLATT, PAUL DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:DAVID
Last Name:GREENBLATT
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:PO BOX 5390
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-0279
Mailing Address - Country:US
Mailing Address - Phone:631-665-3666
Mailing Address - Fax:
Practice Address - Street 1:1855 UNION BLVD
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-7949
Practice Address - Country:US
Practice Address - Phone:631-665-3666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY143934174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00705528Medicaid
NYPG058A6510Medicare ID - Type Unspecified
NYB16866Medicare UPIN