Healthcare Provider Details

I. General information

NPI: 1194728048
Provider Name (Legal Business Name): NORMAN I KORNBLATT D.P.M
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 10/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3666 HIGHWAY 5 STE 101
DOUGLASVILLE GA
30135-6940
US

IV. Provider business mailing address

3666 HIGHWAY 5 STE 101
DOUGLASVILLE GA
30135-6940
US

V. Phone/Fax

Practice location:
  • Phone: 770-942-3668
  • Fax: 770-920-9675
Mailing address:
  • Phone: 770-942-3668
  • Fax: 770-920-9675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number553
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: