Healthcare Provider Details

I. General information

NPI: 1184648909
Provider Name (Legal Business Name): BRIAN BLAISCH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 INTERNATIONAL BLVD SUITE 11
OAKLAND CA
94601-1520
US

IV. Provider business mailing address

2700 INTERNATIONAL BLVD SUITE 11
OAKLAND CA
94601-1520
US

V. Phone/Fax

Practice location:
  • Phone: 510-533-1248
  • Fax: 510-533-1870
Mailing address:
  • Phone: 510-533-1248
  • Fax: 510-533-1870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG64161
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: