Provider Demographics
NPI:1477648087
Name:BLOSSOM, BENJAMIN DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:DAVID
Last Name:BLOSSOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:499 GLOSTER CREEK VLG STE A2
Mailing Address - Street 2:CARDIOLOGY ASSOCIATES OF NORTH MS
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4749
Mailing Address - Country:US
Mailing Address - Phone:662-620-6992
Mailing Address - Fax:
Practice Address - Street 1:499 GLOSTER CREEK VLG
Practice Address - Street 2:SUITE A-2
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4600
Practice Address - Country:US
Practice Address - Phone:662-620-6992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19111207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03670007Medicaid
MS03670007Medicaid