Healthcare Provider Details

I. General information

NPI: 1366478158
Provider Name (Legal Business Name): JEFFREY STUART GOLDBLATT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 09/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 HUNTLEY ROAD SUTIE 1
OLD LYME CT
06371
US

IV. Provider business mailing address

4 HUNTLEY RD SUITE 1
OLD LYME CT
06371-1449
US

V. Phone/Fax

Practice location:
  • Phone: 860-434-4073
  • Fax: 860-434-4635
Mailing address:
  • Phone: 860-434-4073
  • Fax: 860-434-4635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number016369
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: