Provider Demographics
NPI:1790700524
Name:BLOEMENDAL, LEE SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:SCOTT
Last Name:BLOEMENDAL
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:PO BOX 961205
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-1205
Mailing Address - Country:US
Mailing Address - Phone:817-740-8400
Mailing Address - Fax:817-336-8941
Practice Address - Street 1:1325 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 720
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2144
Practice Address - Country:US
Practice Address - Phone:817-810-9495
Practice Address - Fax:817-336-8941
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8284208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX165908801Medicaid
P00226493OtherRAILROAD MEDICARE