Provider Demographics
NPI:1982616835
Name:BARRY A KOBLENTZ DPM INC
Entity Type:Organization
Organization Name:BARRY A KOBLENTZ DPM INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:KOBLENTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:216-291-1515
Mailing Address - Street 1:5035 MAYFIELD RD
Mailing Address - Street 2:215
Mailing Address - City:LYNDHURST
Mailing Address - State:OH
Mailing Address - Zip Code:44124-2688
Mailing Address - Country:US
Mailing Address - Phone:216-291-1515
Mailing Address - Fax:
Practice Address - Street 1:5035 MAYFIELD RD
Practice Address - Street 2:215
Practice Address - City:LYNDHURST
Practice Address - State:OH
Practice Address - Zip Code:44124-2688
Practice Address - Country:US
Practice Address - Phone:216-291-1515
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1541213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2743311Medicaid
OHDG1652Medicare PIN
OH2743311Medicaid