Provider Demographics
NPI:1710104484
Name:BLOMQUIST, GUSTAV A (MD)
Entity Type:Individual
Prefix:DR
First Name:GUSTAV
Middle Name:A
Last Name:BLOMQUIST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 ROSE ST
Mailing Address - Street 2:HX318
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0001
Mailing Address - Country:US
Mailing Address - Phone:832-758-3416
Mailing Address - Fax:
Practice Address - Street 1:800 ROSE ST
Practice Address - Street 2:HX318
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0001
Practice Address - Country:US
Practice Address - Phone:859-323-2411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM60522085R0202X
AL292162085R0202X
FLME1075562085R0202X
GA636342085R0202X
MS209682085R0202X
NC2010-002312085R0202X
SC32233.MD2085R0202X
TNMD00000454512085R0202X
KY437732085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100126970Medicaid
KY7100126970Medicaid