Provider Demographics
NPI:1508378050
Name:LINDBLOOM, ERIC THEODORE IV
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:THEODORE
Last Name:LINDBLOOM
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11495 CARY RD
Mailing Address - Street 2:
Mailing Address - City:ALDEN
Mailing Address - State:NY
Mailing Address - Zip Code:14004-9597
Mailing Address - Country:US
Mailing Address - Phone:716-597-5203
Mailing Address - Fax:
Practice Address - Street 1:665 CLEVELAND DR
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14225-1042
Practice Address - Country:US
Practice Address - Phone:716-836-4949
Practice Address - Fax:716-836-1517
Is Sole Proprietor?:No
Enumeration Date:2017-10-24
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC009722156FC0801X, 156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens Fitter