Provider Demographics
NPI:1689688046
Name:BLUMENFRUCHT, MARVIN JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:JOSEPH
Last Name:BLUMENFRUCHT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:4 FAIRHILL RD
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817-2928
Mailing Address - Country:US
Mailing Address - Phone:908-208-7381
Mailing Address - Fax:212-580-0672
Practice Address - Street 1:385 TREMONT AVE
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-1023
Practice Address - Country:US
Practice Address - Phone:973-676-1000
Practice Address - Fax:212-580-0672
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03998400208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC61021Medicare UPIN