Healthcare Provider Details

I. General information

NPI: 1699793620
Provider Name (Legal Business Name): LAWRENCE KOBLENZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 11/25/2020
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 PORTICO PL STE 1A
GREAT NECK NY
11021-2021
US

IV. Provider business mailing address

32 PORTICO PL STE 1A
GREAT NECK NY
11021-2021
US

V. Phone/Fax

Practice location:
  • Phone: 718-708-7000
  • Fax: 516-482-2462
Mailing address:
  • Phone: 718-708-7000
  • Fax: 516-482-2462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0008X
TaxonomyHepatology Physician
License Number120369
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number120369
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: