Healthcare Provider Details

I. General information

NPI: 1063465490
Provider Name (Legal Business Name): DAVID GREENBLATT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 N VAN DIEN AVE
RIDGEWOOD NJ
07450-2726
US

IV. Provider business mailing address

1 LETHBRIDGE PLZ ROUTE 17 NORTH, SUITE #20
MAHWAH NJ
07430-2126
US

V. Phone/Fax

Practice location:
  • Phone: 201-634-5403
  • Fax: 201-634-5765
Mailing address:
  • Phone: 201-684-1616
  • Fax: 201-684-1661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number25MA04850800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: