Provider Demographics
NPI:1215901244
Name:BLAINE, ROBERT C (DPM)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:C
Last Name:BLAINE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
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Mailing Address - Street 1:16702 VALLEY VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-5824
Mailing Address - Country:US
Mailing Address - Phone:714-367-5360
Mailing Address - Fax:714-635-5428
Practice Address - Street 1:1717 E LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-4345
Practice Address - Country:US
Practice Address - Phone:714-635-2642
Practice Address - Fax:714-635-8547
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2017-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3369213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWE3369CMedicare PIN
CAWE3369BMedicare PIN