Provider Demographics
NPI:1063471274
Name:BLOCH, MIRIAM (MD)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:BLOCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5580 LA JOLLA BLVD
Mailing Address - Street 2:PMB 610
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-7651
Mailing Address - Country:US
Mailing Address - Phone:858-729-0993
Mailing Address - Fax:858-729-0992
Practice Address - Street 1:5580 LA JOLLA BLVD
Practice Address - Street 2:PMB 610
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-7651
Practice Address - Country:US
Practice Address - Phone:858-729-0993
Practice Address - Fax:858-729-0992
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2012-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG61294207ZC0500X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G763090OtherDHS PPIN
CAWG39979EMedicare ID - Type UnspecifiedPPIN
CA00G763090OtherDHS PPIN