Provider Demographics
NPI:1982775748
Name:HOM, XENIA BLYTHE (MD)
Entity type:Individual
Prefix:
First Name:XENIA
Middle Name:BLYTHE
Last Name:HOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:XENIA
Other - Middle Name:BLYTHE HOM
Other - Last Name:RYAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3860 CALLE FORTUNADA
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4800
Mailing Address - Country:US
Mailing Address - Phone:858-309-6303
Mailing Address - Fax:858-309-6301
Practice Address - Street 1:8110 BIRMINGHAM WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2758
Practice Address - Country:US
Practice Address - Phone:858-966-4003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG86642208000000X, 2080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G866420Medicaid