Healthcare Provider Details

I. General information

NPI: 1528463908
Provider Name (Legal Business Name): MICHAEL JOHN BLYTH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2014
Last Update Date: 03/02/2022
Certification Date: 03/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 34TH ST
BAKERSFIELD CA
93301-2107
US

IV. Provider business mailing address

24422 AVENIDA DE LA CARLOTA STE 300
LAGUNA HILLS CA
92653-3628
US

V. Phone/Fax

Practice location:
  • Phone: 661-663-4700
  • Fax: 661-489-3338
Mailing address:
  • Phone: 949-599-2434
  • Fax: 949-599-2430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101256381
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG58537
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: