Provider Demographics
NPI:1457480774
Name:GOLDBLATT, PHILLIP B (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:B
Last Name:GOLDBLATT
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 1:79 TRUMBULL ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-3708
Mailing Address - Country:US
Mailing Address - Phone:203-624-1624
Mailing Address - Fax:
Practice Address - Street 1:79 TRUMBULL ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-3708
Practice Address - Country:US
Practice Address - Phone:203-624-1624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1131042084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry