Healthcare Provider Details

I. General information

NPI: 1952757007
Provider Name (Legal Business Name): STACY GITTEL BLUM D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2016
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10930 N TATUM BLVD STE C101
PHOENIX AZ
85028-6069
US

IV. Provider business mailing address

10930 N TATUM BLVD STE C101
PHOENIX AZ
85028-6069
US

V. Phone/Fax

Practice location:
  • Phone: 480-500-8476
  • Fax: 480-500-8476
Mailing address:
  • Phone: 480-500-8476
  • Fax: 480-500-8476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2020010791
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: