Provider Demographics
NPI:1851378061
Name:BLOSSER, THOMAS L (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:L
Last Name:BLOSSER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:THOMAS
Other - Middle Name:LAURENCE
Other - Last Name:BLOSSER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:655 AFRICA RD
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082-9808
Mailing Address - Country:US
Mailing Address - Phone:614-326-5276
Mailing Address - Fax:614-865-2179
Practice Address - Street 1:655 AFRICA RD
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-9808
Practice Address - Country:US
Practice Address - Phone:614-326-5276
Practice Address - Fax:614-865-2179
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-04-7748207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0542649Medicaid
OH0542649Medicaid
OH0542649Medicaid