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General NPI Number Information
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NPI Number | 1598792616
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Entity Type | Individual
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Provider Name | MORDECAI BLUTH M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/26/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 187 VETERAN'S BLVD
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City | MASSAPEQUA
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State | NY
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Zip | 11758
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Country | US
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Telephone | 718-815-1000
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Fax | 718-815-8122
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Provider Business Mailing Address
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Address Line | 302 MANOR RD
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City | STATEN ISLAND
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State | NY
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Zip | 10314-2408
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Country | US
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Telephone | 718-815-1000
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Fax | 718-815-8122
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 097883
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License Number State | NY
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