Provider Demographics
NPI:1275586059
Name:BLOSSOM, GEORGE B (DO)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:B
Last Name:BLOSSOM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3428 AMBERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43617-1186
Mailing Address - Country:US
Mailing Address - Phone:419-841-5210
Mailing Address - Fax:
Practice Address - Street 1:2526 N REYNOLDS RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-2820
Practice Address - Country:US
Practice Address - Phone:419-537-1485
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34001252207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0784754Medicaid
OH34001252OtherLICENSE NUMBER
OH34001252OtherLICENSE NUMBER