Provider Demographics
NPI:1396782611
Name:KORNBLATT, RALPH (OD)
Entity type:Individual
Prefix:DR
First Name:RALPH
Middle Name:
Last Name:KORNBLATT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374 NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-3316
Mailing Address - Country:US
Mailing Address - Phone:631-421-0250
Mailing Address - Fax:631-421-0827
Practice Address - Street 1:374 NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-3316
Practice Address - Country:US
Practice Address - Phone:631-421-0250
Practice Address - Fax:631-421-0827
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2358152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02243332Medicaid
NYU47023Medicare UPIN
NY02243332Medicaid