Basic Information
| Provider Information | |||||||||
| NPI: | 1952479966 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLOCK-KURBISCH | ||||||||
| FirstName: | INGRID | ||||||||
| MiddleName: | JULIANA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 450 STANYAN STREET | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941171079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4157505890 | ||||||||
| FaxNumber: | 4157505619 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 STANYAN STREET | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941171079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4157505890 | ||||||||
| FaxNumber: | 4157505619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 09/10/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | A49578 | CA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | BB2921612 | 01 | CA | DEA NUMBER | OTHER |