Healthcare Provider Details

I. General information

NPI: 1932250362
Provider Name (Legal Business Name): GARY GOLDBLATT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2007
Last Update Date: 06/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 LYNDON LN SUITE B
LOUISVILLE KY
40222-5550
US

IV. Provider business mailing address

PO BOX 5338
LOUISVILLE KY
40255-0338
US

V. Phone/Fax

Practice location:
  • Phone: 502-896-0707
  • Fax:
Mailing address:
  • Phone: 502-896-0707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number24422
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: