Provider Demographics
NPI:1366497927
Name:BLENNER, DEBORAH (MD)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:BLENNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 MIDDLE COUNTRY RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2857
Mailing Address - Country:US
Mailing Address - Phone:631-656-8171
Mailing Address - Fax:631-656-8173
Practice Address - Street 1:323 MIDDLE COUNTRY RD
Practice Address - Street 2:SUITE 3
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2857
Practice Address - Country:US
Practice Address - Phone:631-656-8171
Practice Address - Fax:631-656-8173
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY238239207R00000X
NV11852207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWBW201Medicare PIN