Healthcare Provider Details

I. General information

NPI: 1841470580
Provider Name (Legal Business Name): DOUGLAS A. BLOSE M.D.,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2007
Last Update Date: 11/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11525 BROOKSHIRE AVE STE 101
DOWNEY CA
90241-4985
US

IV. Provider business mailing address

11525 BROOKSHIRE AVE STE 101
DOWNEY CA
90241-4982
US

V. Phone/Fax

Practice location:
  • Phone: 562-923-6450
  • Fax: 562-923-0049
Mailing address:
  • Phone: 562-923-6450
  • Fax: 562-923-0049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberG50355
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberG50355
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License NumberG50355
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License NumberG50355
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberG50355
License Number StateCA
# 6
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberG50355
License Number StateCA

VIII. Authorized Official

Name: DR. DOUGLAS ALAN BLOSE
Title or Position: PRESIDENT
Credential: M.D
Phone: 562-923-6450