Provider Demographics
NPI:1306816657
Name:BLOSE, DOUGLAS A (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:A
Last Name:BLOSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:11525 BROOKSHIRE AVE
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-4985
Mailing Address - Country:US
Mailing Address - Phone:562-923-6450
Mailing Address - Fax:562-923-0049
Practice Address - Street 1:11525 BROOKSHIRE AVE
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-4985
Practice Address - Country:US
Practice Address - Phone:562-923-6450
Practice Address - Fax:562-923-0049
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG50355207N00000X, 207NI0002X, 207NS0135X, 207ND0900X, 207ND0101X, 207NP0225X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA92968Medicare UPIN