Provider Demographics
NPI:1376501940
Name:BLOM, DENNIS (MD)
Entity Type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:
Last Name:BLOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502
Mailing Address - Country:US
Mailing Address - Phone:315-732-0349
Mailing Address - Fax:315-732-0309
Practice Address - Street 1:2202 GENESEE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502
Practice Address - Country:US
Practice Address - Phone:315-732-0349
Practice Address - Fax:315-732-0309
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1060363A208600000X
NY196361208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03107559Medicaid
NY11535Medicare UPIN
NY03107559Medicaid
NYJ400080436Medicare PIN