Provider Demographics
NPI:1700989670
Name:BLOCH, MARTIN ADAM (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:ADAM
Last Name:BLOCH
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 1:289 WINDHAM RD
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-3528
Mailing Address - Country:US
Mailing Address - Phone:860-465-2650
Mailing Address - Fax:
Practice Address - Street 1:289 WINDHAM RD
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-3528
Practice Address - Country:US
Practice Address - Phone:860-465-2650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCDRH.0042898208M00000X
CT076145207RA0401X, 207R00000X
CO42898207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
COG34882Medicare UPIN