Provider Demographics
NPI:1275597791
Name:BLOMQUIST, MARY D (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:D
Last Name:BLOMQUIST
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 1:6100 WINDCOM CT
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-7886
Mailing Address - Country:US
Mailing Address - Phone:972-398-3500
Mailing Address - Fax:972-398-3512
Practice Address - Street 1:6100 WINDCOM CT
Practice Address - Street 2:SUITE 101
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-7886
Practice Address - Country:US
Practice Address - Phone:972-398-3500
Practice Address - Fax:972-398-3512
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0189207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF24687Medicare UPIN
TX88301KMedicare ID - Type Unspecified
TX88302KMedicare ID - Type Unspecified