Provider Demographics
NPI:1194719302
Name:BLAUROCK, BURTON CHARLES (OD)
Entity type:Individual
Prefix:DR
First Name:BURTON
Middle Name:CHARLES
Last Name:BLAUROCK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42452 BOB HOPE DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-4470
Mailing Address - Country:US
Mailing Address - Phone:760-340-4524
Mailing Address - Fax:760-340-4796
Practice Address - Street 1:42452 BOB HOPE DR
Practice Address - Street 2:SUITE 1
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-4470
Practice Address - Country:US
Practice Address - Phone:760-340-4524
Practice Address - Fax:760-340-4796
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-01
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5996T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0059960Medicaid
CAT10195Medicare UPIN
CASD0059960Medicaid