Provider Demographics
NPI:1184654519
Name:BLOM, JOHANNES VICTOR (MD)
Entity Type:Individual
Prefix:
First Name:JOHANNES
Middle Name:VICTOR
Last Name:BLOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3702 WASHINGTON ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-8282
Mailing Address - Country:US
Mailing Address - Phone:954-964-6114
Mailing Address - Fax:
Practice Address - Street 1:3702 WASHINGTON ST
Practice Address - Street 2:SUITE 202
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-8282
Practice Address - Country:US
Practice Address - Phone:954-964-6114
Practice Address - Fax:954-962-1994
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME94285207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery