Jeffrey Stuart Goldblatt, M.D.
Individual provider Active NPI Surgery Physician · Old Lyme, CT
NPI 1366478158 · NPPES record last updated Sep 19, 2013
Key facts
- NPI
- 1366478158
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Surgery Physician 208600000X
- License
- 016369 (CT)
- Practice address
- 4 Huntley Road
Sutie 1
Old Lyme, CT 06371 - Phone
- (860) 434-4073
- Fax
- (860) 434-4635
- NPI assigned
- Jun 23, 2006
- Sex
- Male
- Sole proprietor
- Yes
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 016369 | CT | MD | Surgery Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Southern Connecticut Vascular Center, LLC | Past | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Surgery Physician | 208600000X | 016369 | CT | Yes |
Addresses
Primary practice location
4 Huntley Road
Sutie 1
Old Lyme, CT 06371
Mailing address
4 Huntley Rd
Suite 1
Old Lyme, CT 06371-1449
Phone (860) 434-4073
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| P3645106 | Other | CT | OXFORD |
| 001163690 | Medicaid | CT | |
| 2590570 | Other | CT | CIGNA |
| 2V5496 | Other | CT | HEALTH NET |
| 65-1212930 | Other | CT | TAX ID |
| 719901J245 | Other | CT | CONNECTICARE |
| 010016369CT03 | Other | CT | ANTHEM BCBS |
| 3444674 | Other | CT | AETNA |
Other providers in Old Lyme, CT
- Cristan Filippi
- Brett J.M. Flynn
- Karl R. Friedmann
- Frontline Wellness LLC
- Shragit Glazman
- Karl M Goldkamp
- Mark Gombotz
- Jay Allan Graves
- Elizabeth Green
- Ruth E Greenblatt
All providers in Old Lyme, CT · Surgery Physician in Connecticut
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 19, 2013. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.