Provider Demographics
NPI:1043310030
Name:BLUM, RICHARD I (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:I
Last Name:BLUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1868 ALTAMIRA PL
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-1202
Mailing Address - Country:US
Mailing Address - Phone:619-890-8107
Mailing Address - Fax:619-296-6865
Practice Address - Street 1:550 WASHINGTON ST STE 641
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2229
Practice Address - Country:US
Practice Address - Phone:619-296-3888
Practice Address - Fax:619-296-3898
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53758207RC0001X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G537580Medicaid
CAG53758Medicare ID - Type Unspecified
CAA14092Medicare UPIN
CA00G537580Medicaid