Provider Demographics
NPI:1932109014
Name:BLECKER JOERG, MERYL (MD)
Entity Type:Individual
Prefix:
First Name:MERYL
Middle Name:
Last Name:BLECKER JOERG
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 1:6 LOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-2810
Mailing Address - Country:US
Mailing Address - Phone:516-326-4160
Mailing Address - Fax:516-437-0482
Practice Address - Street 1:5847 188TH ST
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-2201
Practice Address - Country:US
Practice Address - Phone:718-357-8200
Practice Address - Fax:718-357-5770
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203021207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01990270Medicaid
NY01990270Medicaid
NY06H1401Medicare PIN