Healthcare Provider Details

I. General information

NPI: 1689688046
Provider Name (Legal Business Name): MARVIN JOSEPH BLUMENFRUCHT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 TREMONT AVE
EAST ORANGE NJ
07018-1023
US

IV. Provider business mailing address

4 FAIRHILL RD
EDISON NJ
08817-2928
US

V. Phone/Fax

Practice location:
  • Phone: 973-676-1000
  • Fax: 212-580-0672
Mailing address:
  • Phone: 908-208-7381
  • Fax: 212-580-0672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number25MA03998400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: