Provider Demographics
NPI:1235106279
Name:BLOM, DINA CHRISTINA (MD)
Entity Type:Individual
Prefix:
First Name:DINA
Middle Name:CHRISTINA
Last Name:BLOM
Suffix:
Gender:F
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:PO BOX 366
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25708-0366
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
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21513207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1810976000Medicaid
OH2502134Medicaid
P00116205Medicare ID - Type UnspecifiedR/R MEDICARE
4129581Medicare ID - Type Unspecified
WV1810976000Medicaid