Provider Demographics
NPI:1568471647
Name:BLOMBERG, DAVID JON (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JON
Last Name:BLOMBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1314 S RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55804-1472
Mailing Address - Country:US
Mailing Address - Phone:218-525-7475
Mailing Address - Fax:218-525-4794
Practice Address - Street 1:1314 S RIDGE RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55804-1472
Practice Address - Country:US
Practice Address - Phone:218-525-7475
Practice Address - Fax:218-525-4794
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN18133207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNE97652Medicare UPIN