Provider Demographics
NPI:1295890440
Name:BLUMBERG, DAVID (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BLUMBERG
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 1:325 DISTEL CIR STE 42
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:510-204-8168
Mailing Address - Fax:510-506-7725
Practice Address - Street 1:350 30TH ST STE 411
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609
Practice Address - Country:US
Practice Address - Phone:510-204-8168
Practice Address - Fax:510-506-7725
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD069008L208600000X, 208C00000X
MDD0078428208C00000X
CA605665208C00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD370102YGCZMedicare PIN
P00245038OtherRAILROAD MEDICARE
1509982OtherGATEWAY HEALTH PLAN
PA029035Medicare PIN
206273OtherUPMC HEALTH PLAN
448202OtherHEALTH AMERICA
PA0450535000OtherINDEPENDENCE BLUE SHIELD
PAG99660Medicare UPIN
PA0017589070002Medicaid