Provider Demographics
NPI:1538310917
Name:BLOSSOM, HERBERT JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:HERBERT
Middle Name:JOHN
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 1:550 E SHAW AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-7702
Mailing Address - Country:US
Mailing Address - Phone:559-241-7650
Mailing Address - Fax:559-241-7656
Practice Address - Street 1:550 E SHAW AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-7702
Practice Address - Country:US
Practice Address - Phone:559-241-7650
Practice Address - Fax:559-241-7656
Is Sole Proprietor?:No
Enumeration Date:2008-10-03
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA 24327207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine