Healthcare Provider Details

I. General information

NPI: 1164690905
Provider Name (Legal Business Name): JEROME IRA BLOCK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2008
Last Update Date: 02/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15344 KARL AVE
MONTE SERENO CA
95030-2230
US

IV. Provider business mailing address

15344 KARL AVE
MONTE SERENO CA
95030-2230
US

V. Phone/Fax

Practice location:
  • Phone: 408-395-5809
  • Fax:
Mailing address:
  • Phone: 408-395-5809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG25106
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: