Healthcare Provider Details

I. General information

NPI: 1114023520
Provider Name (Legal Business Name): ANDREW BLITZER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 PROSPECT AVE STE 613
HACKENSACK NJ
07601-1962
US

IV. Provider business mailing address

20 PROSPECT AVE STE 613
HACKENSACK NJ
07601-1962
US

V. Phone/Fax

Practice location:
  • Phone: 212-262-4444
  • Fax: 212-523-8165
Mailing address:
  • Phone: 212-262-9500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberW23126514C
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number120296
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number120296
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier00250197
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: