Provider Demographics
NPI:1598792616
Name:BLUTH, MORDECAI (MD)
Entity Type:Individual
Prefix:DR
First Name:MORDECAI
Middle Name:
Last Name:BLUTH
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 1:302 MANOR RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-2408
Mailing Address - Country:US
Mailing Address - Phone:718-815-1000
Mailing Address - Fax:718-815-8122
Practice Address - Street 1:187 VETERAN'S BLVD
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758
Practice Address - Country:US
Practice Address - Phone:718-815-1000
Practice Address - Fax:718-815-8122
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY097883207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00165811Medicaid
C10919Medicare UPIN
NY00165811Medicaid