Provider Demographics
NPI:1548350804
Name:BLOCK, ELISE ROBIN (MD)
Entity type:Individual
Prefix:DR
First Name:ELISE
Middle Name:ROBIN
Last Name:BLOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELISE
Other - Middle Name:BLOCK
Other - Last Name:GOLD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:12011 SAN VICENTE BLVD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-4926
Mailing Address - Country:US
Mailing Address - Phone:310-472-5758
Mailing Address - Fax:
Practice Address - Street 1:12011 SAN VICENTE BLVD
Practice Address - Street 2:SUITE 250
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-4926
Practice Address - Country:US
Practice Address - Phone:310-472-5758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG511382084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA51908Medicare UPIN