Healthcare Provider Details

I. General information

NPI: 1770586448
Provider Name (Legal Business Name): MITCHELL EDWARD BLUM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 04/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 W. GRANTLINE RD SUITE 250
TRACY CA
95377
US

IV. Provider business mailing address

15 OVAL RD
OAKLAND CA
94611
US

V. Phone/Fax

Practice location:
  • Phone: 209-834-0626
  • Fax: 209-834-1814
Mailing address:
  • Phone: 209-834-0626
  • Fax: 510-817-4235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberG25010
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberG25010
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: