Provider Demographics
NPI:1881614378
Name:BLESA, MARTA IRENE (MD)
Entity type:Individual
Prefix:
First Name:MARTA
Middle Name:IRENE
Last Name:BLESA
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 1:1500 OLD MILL RD
Mailing Address - Street 2:
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91108-1837
Mailing Address - Country:US
Mailing Address - Phone:626-287-8261
Mailing Address - Fax:
Practice Address - Street 1:5821 TEMPLE CITY BLVD
Practice Address - Street 2:
Practice Address - City:TEMPLE CITY
Practice Address - State:CA
Practice Address - Zip Code:91780-2113
Practice Address - Country:US
Practice Address - Phone:626-287-8261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31530207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A31530Medicaid
CA00A31530Medicaid