Provider Demographics
NPI:1265026033
Name:BLOM, CODY PHILIP (OD)
Entity Type:Individual
Prefix:DR
First Name:CODY
Middle Name:PHILIP
Last Name:BLOM
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 1:2780 TEMPEST CT
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-6109
Mailing Address - Country:US
Mailing Address - Phone:406-498-0267
Mailing Address - Fax:
Practice Address - Street 1:1221 DEWEY BLVD
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-3413
Practice Address - Country:US
Practice Address - Phone:406-494-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT3974152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist