Provider Demographics
NPI:1245271089
Name:KORNBLUT, ALAN DAVID (MD FACS)
Entity type:Individual
Prefix:DR
First Name:ALAN
Middle Name:DAVID
Last Name:KORNBLUT
Suffix:
Gender:M
Credentials:MD FACS
Other - Prefix:DR
Other - First Name:ALAN
Other - Middle Name:D
Other - Last Name:KORBLUT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5530 WISCONSIN AVENUE
Mailing Address - Street 2:SUITE 535
Mailing Address - City:CHEVY CHASE
Mailing Address - State:MD
Mailing Address - Zip Code:20815-4451
Mailing Address - Country:US
Mailing Address - Phone:301-657-8834
Mailing Address - Fax:
Practice Address - Street 1:5530 WISCONSIN AVENUE
Practice Address - Street 2:SUITE 535
Practice Address - City:CHEVY CHASE
Practice Address - State:MD
Practice Address - Zip Code:20815-4451
Practice Address - Country:US
Practice Address - Phone:301-657-8834
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD26462207Y00000X
DC12426207Y00000X
VA0101032737207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC04594207Medicaid
DC04594207Medicaid
C88707Medicare UPIN