Healthcare Provider Details

I. General information

NPI: 1700989670
Provider Name (Legal Business Name): MARTIN ADAM BLOCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

289 WINDHAM RD
WILLIMANTIC CT
06226-3528
US

IV. Provider business mailing address

289 WINDHAM RD
WILLIMANTIC CT
06226-3528
US

V. Phone/Fax

Practice location:
  • Phone: 860-465-2650
  • Fax:
Mailing address:
  • Phone: 860-465-2650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberCDRH.0042898
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number076145
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number076145
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number42898
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: