Provider Demographics
NPI:1215589882
Name:BLOM, PAIGE RENAE (OD)
Entity Type:Individual
Prefix:DR
First Name:PAIGE
Middle Name:RENAE
Last Name:BLOM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12448 W HUMMINGBIRD TER
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-2213
Mailing Address - Country:US
Mailing Address - Phone:641-780-9925
Mailing Address - Fax:
Practice Address - Street 1:16860 W WADDELL RD STE 102
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85388-9621
Practice Address - Country:US
Practice Address - Phone:602-643-4054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-12
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOPT-002360152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist