Provider Demographics
NPI:1134242860
Name:BLANK, PHILIP B JR (DO)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:B
Last Name:BLANK
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:325 MANVILLE RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANTVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10570-2122
Mailing Address - Country:US
Mailing Address - Phone:914-747-5600
Mailing Address - Fax:914-747-7085
Practice Address - Street 1:325 MANVILLE RD
Practice Address - Street 2:
Practice Address - City:PLEASANTVILLE
Practice Address - State:NY
Practice Address - Zip Code:10570-2122
Practice Address - Country:US
Practice Address - Phone:914-747-5600
Practice Address - Fax:914-747-7085
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY189508207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF78779Medicare UPIN
A400016883Medicare PIN
NY09U511Medicare ID - Type Unspecified