Provider Demographics
NPI:1003028762
Name:BLOSSOM, EDDYE II (MD)
Entity Type:Individual
Prefix:DR
First Name:EDDYE
Middle Name:
Last Name:BLOSSOM
Suffix:II
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 1:4864 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71202-6400
Mailing Address - Country:US
Mailing Address - Phone:318-330-7626
Mailing Address - Fax:318-330-7648
Practice Address - Street 1:4864 JACKSON ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71202-6400
Practice Address - Country:US
Practice Address - Phone:318-330-7626
Practice Address - Fax:318-330-7648
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.204270207V00000X
TN45438207V00000X
ARE-6247207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2138014Medicaid