Provider Demographics
NPI:1356301568
Name:COBLENTZ, MALCOLM GUY (MD)
Entity Type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:GUY
Last Name:COBLENTZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MALCOLM
Other - Middle Name:GUY
Other - Last Name:COBLENTZ, L.L.C.
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:55 MORRIS AVE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:SPRINGFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07081-1426
Mailing Address - Country:US
Mailing Address - Phone:973-486-0108
Mailing Address - Fax:973-762-5151
Practice Address - Street 1:55 MORRIS AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:SPRINGFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07081-1426
Practice Address - Country:US
Practice Address - Phone:973-486-0108
Practice Address - Fax:973-762-5151
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03059800208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3040305Medicaid
NJC56588Medicare UPIN
NJ3040305Medicaid