Healthcare Provider Details

I. General information

NPI: 1487681342
Provider Name (Legal Business Name): BLAISE W BAXTER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 07/07/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 VAN NESS AVE
SAN FRANCISCO CA
94109-6978
US

IV. Provider business mailing address

325 DISTEL CIR
LOS ALTOS CA
94022-1408
US

V. Phone/Fax

Practice location:
  • Phone: 415-600-7887
  • Fax: 415-369-1395
Mailing address:
  • Phone: 415-600-7887
  • Fax: 415-369-1395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number31416
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberC171504
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberMD19382
License Number StateRI
# 4
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberMD468416
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: