Provider Demographics
NPI:1033161732
Name:BLOMBERG, SCOTT (OD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:
Last Name:BLOMBERG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 N GRAND AVE W
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-2562
Mailing Address - Country:US
Mailing Address - Phone:217-528-3233
Mailing Address - Fax:217-528-4511
Practice Address - Street 1:121 N GRAND AVE W
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-2562
Practice Address - Country:US
Practice Address - Phone:217-528-3233
Practice Address - Fax:217-528-4511
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009526152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL99609Medicare ID - Type Unspecified
IL0762010001Medicare NSC