Healthcare Provider Details

I. General information

NPI: 1235483934
Provider Name (Legal Business Name): GEORGINA MARIE BLANC O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2012
Last Update Date: 06/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 E GRAND AVE
ESCONDIDO CA
92025-4402
US

IV. Provider business mailing address

8230 MIRA MESA BLVD STE B
SAN DIEGO CA
92126-2625
US

V. Phone/Fax

Practice location:
  • Phone: 760-747-7979
  • Fax: 760-747-7799
Mailing address:
  • Phone: 858-566-6670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number14552
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: