Provider Demographics
NPI:1093060253
Name:HUNTINGTON OPHTHALMOLOGY PROFESSIONAL CORP
Entity Type:Organization
Organization Name:HUNTINGTON OPHTHALMOLOGY PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DINA
Authorized Official - Middle Name:CHRISTINE
Authorized Official - Last Name:BLOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-522-8311
Mailing Address - Street 1:1508 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-2902
Mailing Address - Country:US
Mailing Address - Phone:304-522-8311
Mailing Address - Fax:304-522-8313
Practice Address - Street 1:1508 6TH AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-2902
Practice Address - Country:US
Practice Address - Phone:304-522-8311
Practice Address - Fax:304-522-8313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21513207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty