Basic Information
| Provider Information | |||||||||
| NPI: | 1720264310 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROTBLAT | ||||||||
| FirstName: | ELIEZER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 681 TILDEN AVE | ||||||||
| Address2: | |||||||||
| City: | TEANECK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076661847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6462345689 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2534 STEINWAY ST | ||||||||
| Address2: | |||||||||
| City: | ASTORIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 111033702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187775243 | ||||||||
| FaxNumber: | 7187775250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2008 | ||||||||
| LastUpdateDate: | 11/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 015568-1 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 015568-1 | 01 | NY | LICENSE# | OTHER |