Healthcare Provider Details

I. General information

NPI: 1619066099
Provider Name (Legal Business Name): MICHAEL J GREENBLATT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8595 SAINT JOHNS PKWY STE B103
ST AUGUSTINE FL
32092-2064
US

IV. Provider business mailing address

PO BOX 746638
ATLANTA GA
30374-6638
US

V. Phone/Fax

Practice location:
  • Phone: 904-376-4940
  • Fax: 904-376-4943
Mailing address:
  • Phone: 904-202-2092
  • Fax: 904-376-4075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME180517
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number223603
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: