Provider Demographics
NPI:1881663961
Name:KORNBLAU, DINA HALPERN (MD)
Entity Type:Individual
Prefix:
First Name:DINA
Middle Name:HALPERN
Last Name:KORNBLAU
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 1:7941 212TH ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-3505
Mailing Address - Country:US
Mailing Address - Phone:718-479-4541
Mailing Address - Fax:
Practice Address - Street 1:2385 ARTHUR AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-8184
Practice Address - Country:US
Practice Address - Phone:718-220-9755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC190290 12084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01782829-01GPMedicaid