Provider Demographics
NPI:1609872266
Name:KORNBLUTH, IRA (MD)
Entity type:Individual
Prefix:DR
First Name:IRA
Middle Name:
Last Name:KORNBLUTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7920 MCDONOGH RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5273
Mailing Address - Country:US
Mailing Address - Phone:443-693-7246
Mailing Address - Fax:866-906-5997
Practice Address - Street 1:7920 MCDONOGH RD
Practice Address - Street 2:SUITE 201
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-5273
Practice Address - Country:US
Practice Address - Phone:443-693-7246
Practice Address - Fax:866-906-5997
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0061293208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDI06480Medicare UPIN
MD342571YY2LMedicare PIN