Provider Demographics
NPI:1588662019
Name:BLUMBERG, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:BLUMBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3455 MAIN ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01107-1147
Mailing Address - Country:US
Mailing Address - Phone:413-733-9600
Mailing Address - Fax:413-732-6534
Practice Address - Street 1:3455 MAIN ST
Practice Address - Street 2:SUITE 5
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1147
Practice Address - Country:US
Practice Address - Phone:413-733-9600
Practice Address - Fax:413-732-6534
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA223863207N00000X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
223863OtherCONNECTICARE
MAJ28609OtherBLUE CROSS BLUE SHIELD
36373OtherHEALTH NEW ENGLAND
470305OtherTUFTS HEALTH PLANS
P00231584OtherRAILROAD MEDICARE
223863OtherCONNECTICARE
MAJ28609OtherBLUE CROSS BLUE SHIELD