Provider Demographics
NPI:1407235617
Name:BLOSSOM, JONATHAN ASHLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:ASHLEY
Last Name:BLOSSOM
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:499 GLOSTER CREEK VLG
Mailing Address - Street 2:STE A2
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4749
Mailing Address - Country:US
Mailing Address - Phone:662-620-6800
Mailing Address - Fax:662-620-6950
Practice Address - Street 1:499 GLOSTER CREEK VLG STE A2
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4749
Practice Address - Country:US
Practice Address - Phone:662-620-6801
Practice Address - Fax:662-377-2403
Is Sole Proprietor?:No
Enumeration Date:2015-05-20
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MST-2913207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine