Provider Demographics
NPI:1356717854
Name:MITCHELL E. BLUM M.D., F.A.C.S., INC.
Entity type:Organization
Organization Name:MITCHELL E. BLUM M.D., F.A.C.S., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:E
Authorized Official - Last Name:BLUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-834-0626
Mailing Address - Street 1:2160 W GRANT LINE RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95377-7330
Mailing Address - Country:US
Mailing Address - Phone:209-834-0626
Mailing Address - Fax:209-834-1814
Practice Address - Street 1:2160 W GRANT LINE RD
Practice Address - Street 2:SUITE 250
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95377-7330
Practice Address - Country:US
Practice Address - Phone:209-834-0626
Practice Address - Fax:209-834-1814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-19
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG25010207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Single Specialty