Provider Demographics
NPI:1407824410
Name:BLUM, JONATHAN A (DPM)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:A
Last Name:BLUM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 OAK COMMONS BLVD
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741
Mailing Address - Country:US
Mailing Address - Phone:407-846-6004
Mailing Address - Fax:407-846-1330
Practice Address - Street 1:604 OAK COMMONS BLVD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741
Practice Address - Country:US
Practice Address - Phone:407-846-6004
Practice Address - Fax:407-846-1330
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2633213E00000X
FLPO02633213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
65525Medicare ID - Type Unspecified
U69492Medicare UPIN