Provider Demographics
NPI:1962491654
Name:GOLDBLUM, LESTER FREDERICK (DO)
Entity Type:Individual
Prefix:
First Name:LESTER
Middle Name:FREDERICK
Last Name:GOLDBLUM
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 1:850 HICKSVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SEAFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11783-1300
Mailing Address - Country:US
Mailing Address - Phone:516-796-9000
Mailing Address - Fax:516-796-6360
Practice Address - Street 1:850 HICKSVILLE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SEAFORD
Practice Address - State:NY
Practice Address - Zip Code:11783-1300
Practice Address - Country:US
Practice Address - Phone:516-796-9000
Practice Address - Fax:516-796-6360
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY 143486207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
34D121Medicare ID - Type Unspecified
D47331Medicare UPIN