Healthcare Provider Details

I. General information

NPI: 1962491654
Provider Name (Legal Business Name): LESTER FREDERICK GOLDBLUM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 12/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 HICKSVILLE RD SUITE 100
SEAFORD NY
11783-1300
US

IV. Provider business mailing address

850 HICKSVILLE RD SUITE 100
SEAFORD NY
11783-1300
US

V. Phone/Fax

Practice location:
  • Phone: 516-796-9000
  • Fax: 516-796-6360
Mailing address:
  • Phone: 516-796-9000
  • Fax: 516-796-6360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberNY 143486
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: