Healthcare Provider Details

I. General information

NPI: 1316141161
Provider Name (Legal Business Name): JONATHAN A BLAU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 07/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 SEAVIEW AVE DEPT. OF PEDIATRICS
STATEN ISLAND NY
10305-3436
US

IV. Provider business mailing address

1 EDGEWATER ST 6TH FL.
STATEN ISLAND NY
10305-4907
US

V. Phone/Fax

Practice location:
  • Phone: 718-226-8123
  • Fax: 718-226-1128
Mailing address:
  • Phone: 718-226-1008
  • Fax: 718-226-1039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number242947
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: