Healthcare Provider Details

I. General information

NPI: 1063471274
Provider Name (Legal Business Name): MIRIAM BLOCH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 02/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5580 LA JOLLA BLVD PMB 610
LA JOLLA CA
92037-7651
US

IV. Provider business mailing address

5580 LA JOLLA BLVD PMB 610
LA JOLLA CA
92037-7651
US

V. Phone/Fax

Practice location:
  • Phone: 858-729-0993
  • Fax: 858-729-0992
Mailing address:
  • Phone: 858-729-0993
  • Fax: 858-729-0992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License NumberG61294
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberG61294
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: