Provider Demographics
NPI:1447745807
Name:BLOTKY, ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:BLOTKY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 SILVERWOOD TER
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-1448
Mailing Address - Country:US
Mailing Address - Phone:310-890-8975
Mailing Address - Fax:
Practice Address - Street 1:PEDIATRIC ASSOCIATES MEDICAL GROUP
Practice Address - Street 2:4330 FULTON AVENUE
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423
Practice Address - Country:US
Practice Address - Phone:818-784-1102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA165305208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program