Provider Demographics
NPI:1467644187
Name:BLUCK, SCOTT LEE (DO)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:LEE
Last Name:BLUCK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:855 BEECH ST
Mailing Address - Street 2:APT 207
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2885
Mailing Address - Country:US
Mailing Address - Phone:619-992-5446
Mailing Address - Fax:
Practice Address - Street 1:8010 PARKWAY DR
Practice Address - Street 2:DEPT OF FAMILY MEDICINE
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-2104
Practice Address - Country:US
Practice Address - Phone:619-528-6111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-16
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA20A9096207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine