Provider Demographics
NPI:1811082571
Name:BLUM, LAWRENCE ROY (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:ROY
Last Name:BLUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:572 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-7370
Mailing Address - Country:US
Mailing Address - Phone:212-751-8374
Mailing Address - Fax:212-751-8379
Practice Address - Street 1:572 PARK AVENUE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021
Practice Address - Country:US
Practice Address - Phone:212-751-8374
Practice Address - Fax:212-751-8379
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY188611207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01500678Medicaid
NY01500678Medicaid
NY02J571Medicare UPIN