Provider Demographics
NPI:1942566740
Name:KORNBLATT, BENJAMIN L (DO)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:L
Last Name:KORNBLATT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 551420
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33355-1420
Mailing Address - Country:US
Mailing Address - Phone:800-243-3839
Mailing Address - Fax:855-851-4405
Practice Address - Street 1:5353 REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-6015
Practice Address - Country:US
Practice Address - Phone:912-355-7214
Practice Address - Fax:912-354-2479
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-05
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102205062207L00000X
390200000X
GA076305207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program