Basic Information
| Provider Information | |||||||||
| NPI: | 1235156738 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLUMENSTOCK | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | MARTIN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 365 HAWTHORNE AVE | ||||||||
| Address2: | STE 301 | ||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946093113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108931700 | ||||||||
| FaxNumber: | 5108930110 | ||||||||
| Practice Location | |||||||||
| Address1: | 365 HAWTHORNE AVE | ||||||||
| Address2: | STE 301 | ||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946093113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108931700 | ||||||||
| FaxNumber: | 5108930110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | G22905 | CA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 00G229050 | 05 | CA | MEDICAID |