Provider Demographics
NPI:1821452715
Name:BLUMBERG, DREW
Entity Type:Individual
Prefix:
First Name:DREW
Middle Name:
Last Name:BLUMBERG
Suffix:
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 1:1649 LUCERNE ST
Mailing Address - Street 2:
Mailing Address - City:MINDEN
Mailing Address - State:NV
Mailing Address - Zip Code:89423-4369
Mailing Address - Country:US
Mailing Address - Phone:775-782-1603
Mailing Address - Fax:
Practice Address - Street 1:200 MULLINS DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-3983
Practice Address - Country:US
Practice Address - Phone:541-259-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-07
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CODR.0062943207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program